Provider Demographics
NPI:1720434657
Name:HAZLETT, KYMBERLY DIANN (ME)
Entity Type:Individual
Prefix:
First Name:KYMBERLY
Middle Name:DIANN
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:ME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-3211
Mailing Address - Country:US
Mailing Address - Phone:405-331-2305
Mailing Address - Fax:580-272-5734
Practice Address - Street 1:124 E MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5623
Practice Address - Country:US
Practice Address - Phone:580-310-7993
Practice Address - Fax:580-272-5734
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator