Healthcare Provider Details

I. General information

NPI: 1851929335
Provider Name (Legal Business Name): HANNAH HAZLEWOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 11/01/2020
Certification Date: 11/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 CALUMET AVE STE N203
MUNSTER IN
46321-5810
US

IV. Provider business mailing address

4601 N RAVENSWOOD AVE UNIT 309
CHICAGO IL
60640-4572
US

V. Phone/Fax

Practice location:
  • Phone: 219-228-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: