Provider Demographics
NPI:1639872666
Name:HAGEN, PAMELA JEAN
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:JEAN
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7073 156TH AVE. NE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-8808
Mailing Address - Country:US
Mailing Address - Phone:701-352-1343
Mailing Address - Fax:
Practice Address - Street 1:7073 156TH AVE. NE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237-8808
Practice Address - Country:US
Practice Address - Phone:701-352-1343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty