Provider Demographics
NPI:1689802993
Name:HAZLEY, KERRIAN A (MD)
Entity Type:Individual
Prefix:MS
First Name:KERRIAN
Middle Name:A
Last Name:HAZLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 STATE HIGHWAY 83
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-3800
Mailing Address - Country:US
Mailing Address - Phone:850-892-8015
Mailing Address - Fax:850-892-8457
Practice Address - Street 1:362 STATE HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-3800
Practice Address - Country:US
Practice Address - Phone:850-892-8015
Practice Address - Fax:850-892-8457
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051502207Q00000X
FLME117182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011940500Medicaid
FLHU548ZMedicare PIN