MEDICARE: JERICA SHEA HAZELWOOD FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	906726	MS

General Provider Information

NPI Number	:	1740023688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERICA SHEA HAZELWOOD FNP-BC

Provider Business Mailing Address
First Line	:	209 MAIN ST
Second Line	:
City	:	UNION
State	:	MS
Zip	:	39365-2521
Country	:	US
Telephone Number	:	769-222-7008
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 MAIN ST
Second Line	:
City	:	UNION
State	:	MS
Zip	:	39365-2521
Country	:	US
Telephone Number	:	769-222-7008
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2024
Last Update Date	:	06/18/2024

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