Provider Demographics
NPI:1881625457
Name:MEAD, HAZEL E (NP)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:E
Last Name:MEAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-0308
Mailing Address - Country:US
Mailing Address - Phone:912-526-8108
Mailing Address - Fax:912-526-6504
Practice Address - Street 1:714 NW BROAD STREET
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-0008
Practice Address - Country:US
Practice Address - Phone:912-526-8108
Practice Address - Fax:912-526-6504
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN029227163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA42BBBFBMedicare ID - Type UnspecifiedTOOMBS WELLNESS
GAS063464Medicare UPIN