Basic Information
| Provider Information | |||||||||
| NPI: | 1609216134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | A.P.R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5129 DIXIE HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Practice Location | |||||||||
| Address1: | 5129 DIXIE HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024478786 | ||||||||
| FaxNumber: | 5024478623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3008094 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3008094 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2100X | 3008094 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 7100244950 | 05 | KY | MEDICAID | 201183870 | 05 | IN | MEDICAID |