Provider Demographics
NPI:1285915256
Name:HAZELWOOD, SANDRA LUCINDA (APRN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LUCINDA
Last Name:HAZELWOOD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 GARDINER LN STE 207
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2948
Mailing Address - Country:US
Mailing Address - Phone:502-777-9961
Mailing Address - Fax:502-379-8791
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-777-9961
Practice Address - Fax:502-379-8791
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004745A363L00000X
KY3007116363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201090670Medicaid
KY7100194850Medicaid
IN201090670Medicaid
ININ1888002Medicare PIN
KYK028630Medicare PIN