Provider Demographics
NPI:1699553693
Name:VALDIVIA, HAZELL GRACIELA (APRN)
Entity type:Individual
Prefix:
First Name:HAZELL
Middle Name:GRACIELA
Last Name:VALDIVIA
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 1:83 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2031
Mailing Address - Country:US
Mailing Address - Phone:321-842-9863
Mailing Address - Fax:321-843-2068
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2031
Practice Address - Country:US
Practice Address - Phone:321-842-9863
Practice Address - Fax:321-843-2068
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL367A00000X
FLAPRN11029027367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12057000Medicaid