Provider Demographics
NPI:1699862581
Name:HAGARTY, MICHELE ANETTE (APN)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ANETTE
Last Name:HAGARTY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 ACORN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-4446
Mailing Address - Country:US
Mailing Address - Phone:618-628-6378
Mailing Address - Fax:
Practice Address - Street 1:300 W LINCOLN ST
Practice Address - Street 2:SUITE 402
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1987
Practice Address - Country:US
Practice Address - Phone:618-277-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004878363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041209241Medicaid
ILK07717Medicare ID - Type Unspecified