Provider Demographics
NPI:1700620838
Name:HAGEN, AMANDA LOUISE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:HAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2627
Mailing Address - Country:US
Mailing Address - Phone:503-744-7557
Mailing Address - Fax:
Practice Address - Street 1:310 N SCHOOL ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2627
Practice Address - Country:US
Practice Address - Phone:503-744-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000111511374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000111511OtherOREGON HEALTH AUTHORITY THW