Provider Demographics
NPI:1043693914
Name:HAZELETT, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:HAZELETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N LINKS DR APT 2122
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-3057
Mailing Address - Country:US
Mailing Address - Phone:480-201-2681
Mailing Address - Fax:
Practice Address - Street 1:10110 S 7650 E
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022-0009
Practice Address - Country:US
Practice Address - Phone:406-638-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN158642163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse