Provider Demographics
NPI:1336025592
Name:HAZELWOOD, LIBBI
Entity type:Individual
Prefix:
First Name:LIBBI
Middle Name:
Last Name:HAZELWOOD
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 1:421 E 8220 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-0422
Mailing Address - Country:US
Mailing Address - Phone:402-980-4221
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12253981-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered