Provider Demographics
NPI:1003206756
Name:HAZELY, LAURA JAYNE (APN, CNM)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JAYNE
Last Name:HAZELY
Suffix:
Gender:F
Credentials:APN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH BLVD E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6122
Mailing Address - Country:US
Mailing Address - Phone:248-997-5805
Mailing Address - Fax:248-997-5811
Practice Address - Street 1:1701 SOUTH BLVD E
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6122
Practice Address - Country:US
Practice Address - Phone:248-997-5805
Practice Address - Fax:248-997-5811
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012304367A00000X
MI4704320496367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife