Provider Demographics
NPI:1326066622
Name:ELDRIDGE, HAZEL ILENE (ARNP)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:ILENE
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:ARNP
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 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:606-633-1874
Practice Address - Street 1:464 KY HIGHWAY 699
Practice Address - Street 2:
Practice Address - City:CORNETTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41731-8749
Practice Address - Country:US
Practice Address - Phone:606-476-2593
Practice Address - Fax:606-476-2347
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004613363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78014958Medicaid
KYQ50002Medicare UPIN
KY0290508Medicare PIN
KY0994606Medicare PIN