Healthcare Provider Details

I. General information

NPI: 1588268049
Provider Name (Legal Business Name): LUCY IRENE HAZELWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 PENNSYLVANIA AVE
CHARLESTON WV
25302-4835
US

IV. Provider business mailing address

213 W MAIN ST
SAINT ALBANS WV
25177-2610
US

V. Phone/Fax

Practice location:
  • Phone: 304-965-9081
  • Fax: 304-346-1860
Mailing address:
  • Phone: 304-561-5750
  • Fax: 304-471-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: