Provider Demographics
NPI:1104170455
Name:HAGAR, KATRINA
Entity type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:
Last Name:HAGAR
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 1:15218 RIDPATH AVE
Mailing Address - Street 2:UNIT. UP
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-1708
Mailing Address - Country:US
Mailing Address - Phone:216-288-3937
Mailing Address - Fax:
Practice Address - Street 1:15218 RIDPATH AVE
Practice Address - Street 2:UNIT. UP
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1708
Practice Address - Country:US
Practice Address - Phone:216-288-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.145891-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse