Provider Demographics
NPI:1578134979
Name:HAZEL, TORI RAYE (AGCNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:TORI
Middle Name:RAYE
Last Name:HAZEL
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 RUTH RD
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1236
Mailing Address - Country:US
Mailing Address - Phone:580-471-8171
Mailing Address - Fax:
Practice Address - Street 1:1200 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5702
Practice Address - Country:US
Practice Address - Phone:580-379-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204080364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology