Provider Demographics
NPI:1265677074
Name:HAZELTINE, JEREMY W
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:W
Last Name:HAZELTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JEREMY
Other - Middle Name:W
Other - Last Name:HAZELTINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:511 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2427
Mailing Address - Country:US
Mailing Address - Phone:937-778-1132
Mailing Address - Fax:
Practice Address - Street 1:511 HARRISON ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2427
Practice Address - Country:US
Practice Address - Phone:937-778-1132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132938 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse