Provider Demographics
NPI:1083299325
Name:HAZLEWOOD, CAMILLE
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:HAZLEWOOD
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 1:4407 DREXEL AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-1901
Mailing Address - Country:US
Mailing Address - Phone:321-356-7814
Mailing Address - Fax:
Practice Address - Street 1:905 HISTORIC GOLDSBORO BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2415
Practice Address - Country:US
Practice Address - Phone:407-337-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1009892363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner