Provider Demographics
NPI:1144827734
Name:HAGNER, KELLY MARIE (APNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:HAGNER
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3734
Mailing Address - Country:US
Mailing Address - Phone:920-926-4100
Mailing Address - Fax:920-926-4190
Practice Address - Street 1:480 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3734
Practice Address - Country:US
Practice Address - Phone:920-926-4100
Practice Address - Fax:920-926-4190
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10452-33363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner