Healthcare Provider Details

I. General information

NPI: 1497994024
Provider Name (Legal Business Name): MRS. VICKI JO HAZLEWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 S 950 E
LAFAYETTE IN
47905-9447
US

IV. Provider business mailing address

PO BOX 186
STOCKWELL IN
47983-0186
US

V. Phone/Fax

Practice location:
  • Phone: 765-296-7905
  • Fax: 765-296-7906
Mailing address:
  • Phone: 765-296-7905
  • Fax: 765-296-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number28154421A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: