Provider Demographics
NPI:1689340374
Name:HAZELWOOD, CLIFFORD LEE
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:LEE
Last Name:HAZELWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-9313
Mailing Address - Country:US
Mailing Address - Phone:270-786-3313
Mailing Address - Fax:
Practice Address - Street 1:4470 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-9313
Practice Address - Country:US
Practice Address - Phone:270-763-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1092982163W00000X
KY3017161367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse