Provider Demographics
NPI:1902414527
Name:HAZEN, MICHELLE DAWN (APRN-CNP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DAWN
Last Name:HAZEN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 ROBINSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9194
Mailing Address - Country:US
Mailing Address - Phone:208-761-2408
Mailing Address - Fax:
Practice Address - Street 1:831 S ASH ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-885-6693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID65286363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily