1740542794 NPI number — DR. HAZLE COURTNEY BALLINA APRN

Table of content: DR. HAZLE COURTNEY BALLINA APRN (NPI 1740542794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740542794 NPI number — DR. HAZLE COURTNEY BALLINA APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLINA
Provider First Name:
HAZLE
Provider Middle Name:
COURTNEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALLINA
Provider Other First Name:
H.
Provider Other Middle Name:
COURTNEY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1740542794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1283 BLUE JAY PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW RICHMOND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54017-2586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1480 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALDWIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54002-9342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-544-7446
Provider Business Practice Location Address Fax Number:
651-412-7599
Provider Enumeration Date:
06/14/2012

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: 363LF0000X , with the licence number:  R-207943-7 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 6332 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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