Provider Demographics
NPI:1750007431
Name:HAZELTINE, AMANDA MARIE DALIA (DNP, MS, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE DALIA
Last Name:HAZELTINE
Suffix:
Gender:F
Credentials:DNP, MS, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 BEVERLY BLVD BLDG SUITE220
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD BLDG SUITE220
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-9520
Practice Address - Fax:310-423-9525
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2346236363L00000X
CANP95027398363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner