Provider Demographics
NPI:1194206458
Name:HATHORN, HAZEL DARLENE (LVN)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:DARLENE
Last Name:HATHORN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 651
Mailing Address - Street 2:
Mailing Address - City:ARANSAS PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78335-0651
Mailing Address - Country:US
Mailing Address - Phone:361-226-6198
Mailing Address - Fax:
Practice Address - Street 1:512 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:TX
Practice Address - Zip Code:78343-3103
Practice Address - Country:US
Practice Address - Phone:361-226-6198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX151871164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse