Provider Demographics
NPI:1811505928
Name:HAZELEY, KEMBA (NNP-BC)
Entity type:Individual
Prefix:
First Name:KEMBA
Middle Name:
Last Name:HAZELEY
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N 3RD AVE APT 3U
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-1375
Mailing Address - Country:US
Mailing Address - Phone:845-323-5620
Mailing Address - Fax:
Practice Address - Street 1:1825 EASTCHESTER RD FL 5N
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-904-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF350491363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care