Provider Demographics
NPI:1740747278
Name:HAZEN, QUAILLA MARRIANNE
Entity Type:Individual
Prefix:
First Name:QUAILLA
Middle Name:MARRIANNE
Last Name:HAZEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-5123
Mailing Address - Country:US
Mailing Address - Phone:580-762-1462
Mailing Address - Fax:580-765-7299
Practice Address - Street 1:620 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5123
Practice Address - Country:US
Practice Address - Phone:580-762-1462
Practice Address - Fax:580-765-7299
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management