Provider Demographics
NPI:1619164480
Name:HAZEL, ELLEN MARIE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:MARIE
Last Name:HAZEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 37TH PLACE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-257-8700
Mailing Address - Fax:
Practice Address - Street 1:1055 37TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6551
Practice Address - Country:US
Practice Address - Phone:772-257-8700
Practice Address - Fax:772-257-8715
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC144650367500000X
FLARNP 9363178367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050945Medicaid
NC2615093Medicare PIN