Provider Demographics
NPI:1578016598
Name:HAZLETT, SUSAN M (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 ELM TREE RD S
Mailing Address - Street 2:
Mailing Address - City:SAINT PARIS
Mailing Address - State:OH
Mailing Address - Zip Code:43072-9631
Mailing Address - Country:US
Mailing Address - Phone:937-605-5615
Mailing Address - Fax:
Practice Address - Street 1:4400 ELM TREE RD S
Practice Address - Street 2:
Practice Address - City:SAINT PARIS
Practice Address - State:OH
Practice Address - Zip Code:43072-9631
Practice Address - Country:US
Practice Address - Phone:937-605-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019489363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health