Provider Demographics
NPI:1558655027
Name:HAZELITT, MARIANNE (DO)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:HAZELITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:5320 S RAINBOW BLVD STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1807
Practice Address - Country:US
Practice Address - Phone:702-944-7105
Practice Address - Fax:702-944-7110
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO2191207R00000X
FLUO2769207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDO2191OtherSTATE LICENSE
NV1558655027Medicaid