Provider Demographics
NPI:1255098935
Name:HAZLETT, KRISTEN LASSITER (PTA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LASSITER
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 BELMONT DR APT 202
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-6499
Mailing Address - Country:US
Mailing Address - Phone:985-264-0957
Mailing Address - Fax:
Practice Address - Street 1:3726B BATTLEGROUND AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2344
Practice Address - Country:US
Practice Address - Phone:336-265-6731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6123225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant