Provider Demographics
NPI:1912488040
Name:MEDINA, HAZEL
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-1638
Mailing Address - Country:US
Mailing Address - Phone:702-748-3839
Mailing Address - Fax:
Practice Address - Street 1:5000 W OAKEY BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3393
Practice Address - Country:US
Practice Address - Phone:702-733-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV372500000X, 372600000X, 3747A0650X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker