Provider Demographics
NPI:1154916807
Name:HAGERMAN, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HAGERMAN
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:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:JOLO
Mailing Address - State:WV
Mailing Address - Zip Code:24850-0218
Mailing Address - Country:US
Mailing Address - Phone:304-967-6039
Mailing Address - Fax:
Practice Address - Street 1:H R1178 GROUNDING BRANCD
Practice Address - Street 2:
Practice Address - City:JOLO
Practice Address - State:WV
Practice Address - Zip Code:24850
Practice Address - Country:US
Practice Address - Phone:304-967-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker