=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588022776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE HAZELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2016
-----------------------------------------------------
Last Update Date | 02/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2621 NE 134TH ST STE 300
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-718-2355
-----------------------------------------------------
Fax | 360-828-7782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2621 NE 134TH ST STE 300
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-718-2355
-----------------------------------------------------
Fax | 360-828-7782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | IL 60564805
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------