Provider Demographics
NPI:1164553343
Name:HAZELTINE, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HAZELTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WALLEN DR
Mailing Address - Street 2:
Mailing Address - City:VAN LEAR
Mailing Address - State:KY
Mailing Address - Zip Code:41265-9045
Mailing Address - Country:US
Mailing Address - Phone:606-793-7953
Mailing Address - Fax:
Practice Address - Street 1:115 WALLEN DR
Practice Address - Street 2:
Practice Address - City:VAN LEAR
Practice Address - State:KY
Practice Address - Zip Code:41265-9045
Practice Address - Country:US
Practice Address - Phone:606-793-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25775261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64257751Medicaid
KYE01402Medicare UPIN