Provider Demographics
NPI:1114134970
Name:HAZEN, THERESE MARIE (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:MARIE
Last Name:HAZEN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4799 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-5732
Mailing Address - Country:US
Mailing Address - Phone:440-479-2780
Mailing Address - Fax:
Practice Address - Street 1:4799 MAPLE ST
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-5732
Practice Address - Country:US
Practice Address - Phone:440-479-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 222531163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant