Healthcare Provider Details

I. General information

NPI: 1144069949
Provider Name (Legal Business Name): HOLLY D HAZARD APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY D HARE

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W 1ST ST
WEWOKA OK
74884-2103
US

IV. Provider business mailing address

PO BOX 236
WETUMKA OK
74883-0236
US

V. Phone/Fax

Practice location:
  • Phone: 405-257-5422
  • Fax: 405-257-5463
Mailing address:
  • Phone: 405-257-5422
  • Fax: 405-257-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number220118
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1158948
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: