Provider Demographics
NPI:1235311911
Name:HAZEL, TERRIE LAVERN (DNP)
Entity type:Individual
Prefix:
First Name:TERRIE
Middle Name:LAVERN
Last Name:HAZEL
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 MICA CV
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-3282
Mailing Address - Country:US
Mailing Address - Phone:803-426-3087
Mailing Address - Fax:
Practice Address - Street 1:651 MICA CV
Practice Address - Street 2:
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829-3282
Practice Address - Country:US
Practice Address - Phone:803-426-3087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN179434163WA2000X, 163WG0000X, 163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606317BMedicaid