Healthcare Provider Details

I. General information

NPI: 1558504076
Provider Name (Legal Business Name): NICOLE R HAZELWOOD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 ELM ST
JACKSON MO
63755-1708
US

IV. Provider business mailing address

216 ELM ST
JACKSON MO
63755-1708
US

V. Phone/Fax

Practice location:
  • Phone: 573-576-1903
  • Fax:
Mailing address:
  • Phone: 573-576-1903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041429789
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2002019453
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: