Provider Demographics
NPI:1376159673
Name:HAZLE, MARY ELLEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:HAZLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 RUBERTA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1409
Mailing Address - Country:US
Mailing Address - Phone:818-257-4754
Mailing Address - Fax:
Practice Address - Street 1:1219 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2201
Practice Address - Country:US
Practice Address - Phone:818-662-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily