Provider Demographics
NPI:1992708671
Name:HAGEMANN, BRENDA KAY (MSN, APRN, BC FNP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAY
Last Name:HAGEMANN
Suffix:
Gender:F
Credentials:MSN, APRN, BC FNP
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:KAY
Other - Last Name:HEWLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, BC FNP
Mailing Address - Street 1:420 N. 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:208-263-0450
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-9750
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-2313
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP300A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804211800Medicaid
ID1341713Medicare ID - Type UnspecifiedIDAHO MEDICARE PROV #
IDS40919Medicare UPIN