Provider Demographics
NPI:1093515389
Name:SMITH, HAZELNUT WEINER
Entity type:Individual
Prefix:
First Name:HAZELNUT
Middle Name:WEINER
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SAUNDERS RD
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:ME
Mailing Address - Zip Code:04236-4105
Mailing Address - Country:US
Mailing Address - Phone:207-240-8199
Mailing Address - Fax:
Practice Address - Street 1:9 HASTINGS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2057
Practice Address - Country:US
Practice Address - Phone:207-240-8199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-15
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty