Provider Demographics
NPI:1801601042
Name:HAZELTON, FAWN
Entity type:Individual
Prefix:MRS
First Name:FAWN
Middle Name:
Last Name:HAZELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:FAWN
Other - Middle Name:
Other - Last Name:RADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:704 RILEY AVE
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:NE
Mailing Address - Zip Code:68337
Mailing Address - Country:US
Mailing Address - Phone:402-862-5299
Mailing Address - Fax:
Practice Address - Street 1:704 RILEY AVE
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:NE
Practice Address - Zip Code:68337-4034
Practice Address - Country:US
Practice Address - Phone:402-862-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
NE124326376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide