MEDICARE: DR. OZZIE AMENDA HAIRSTON DNP, PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61379476	WA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1012284	TX
3	163W00000X	Registered Nurse	RN61379474	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1012284	OTHER	TX	TEXAS STATE 1012284

General Provider Information

NPI Number	:	1588893978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OZZIE AMENDA HAIRSTON DNP, PMHNP

Provider Business Mailing Address
First Line	:	4526 FEDERAL AVE
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98203-2132
Country	:	US
Telephone Number	:	425-349-6200
Fax Number	:	713-583-1431

Provider Business Practice Location Address
First Line	:	4111 ROSE LAKE DR STE 8922
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-2829
Country	:	US
Telephone Number	:	281-406-1112
Fax Number	:	713-583-2081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2009
Last Update Date	:	11/21/2025

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