Healthcare Provider Details

I. General information

NPI: 1134585102
Provider Name (Legal Business Name): INGRID HAZLETT APRN, AGCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INGRID HEDSTROM

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 02/10/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N ORANGE ST STE 304
MISSOULA MT
59802-2951
US

IV. Provider business mailing address

PO BOX 12
LIBERTY LAKE WA
99019-0012
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5781
  • Fax: 406-327-3331
Mailing address:
  • Phone: 406-329-5781
  • Fax: 406-327-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberNUR-APRN-LIC-126570
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberAPN.0992090-CNS
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberNUR-APRN-LIC-126570
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: