Healthcare Provider Details

I. General information

NPI: 1114134970
Provider Name (Legal Business Name): THERESE MARIE HAZEN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4799 MAPLE ST
WILLOUGHBY OH
44094-5732
US

IV. Provider business mailing address

4799 MAPLE ST
WILLOUGHBY OH
44094-5732
US

V. Phone/Fax

Practice location:
  • Phone: 440-479-2780
  • Fax:
Mailing address:
  • Phone: 440-479-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN 222531
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: