1558504076 NPI number — NICOLE R HAZELWOOD CRNA

Table of content: NICOLE R HAZELWOOD CRNA (NPI 1558504076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558504076 NPI number — NICOLE R HAZELWOOD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAZELWOOD
Provider First Name:
NICOLE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558504076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63755-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-576-1903
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63755-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-576-1903
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  041429789 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 2002019453 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110375 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00726014 . This is a "RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".