Provider Demographics
NPI:1962641431
Name:BAZZELL, LARESSA FAY (MSN, CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LARESSA
Middle Name:FAY
Last Name:BAZZELL
Suffix:
Gender:F
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 N 12TH ST # 230
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-1651
Mailing Address - Country:US
Mailing Address - Phone:270-210-8873
Mailing Address - Fax:
Practice Address - Street 1:632 N 12TH ST # 230
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1651
Practice Address - Country:US
Practice Address - Phone:270-210-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005904367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK014580Medicare Oscar/Certification
KYK014581Medicare PIN