Healthcare Provider Details

I. General information

NPI: 1881625457
Provider Name (Legal Business Name): HAZEL E MEAD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 NW BROAD STREET
LYONS GA
30436-0008
US

IV. Provider business mailing address

PO BOX 308
LYONS GA
30436-0308
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-8108
  • Fax: 912-526-6504
Mailing address:
  • Phone: 912-526-8108
  • Fax: 912-526-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN029227
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN029227
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: