Healthcare Provider Details

I. General information

NPI: 1770297061
Provider Name (Legal Business Name): CODY HAZEN WAKEFIELD CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 HOLIDAY INN RD
CLARION PA
16214-4034
US

IV. Provider business mailing address

265 HOLIDAY INN RD
CLARION PA
16214-4034
US

V. Phone/Fax

Practice location:
  • Phone: 814-297-8848
  • Fax: 814-297-8845
Mailing address:
  • Phone: 814-297-8848
  • Fax: 814-297-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP026811
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: