Basic Information
| Provider Information | |||||||||
| NPI: | 1083228092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAZEMAN | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | DENEILLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENSON | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | DENEILLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19170 JASPER ST NW | ||||||||
| Address2: | |||||||||
| City: | ANOKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553039639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128677331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2020 | ||||||||
| LastUpdateDate: | 09/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0002X | 204419-0 | MN | Y | Nursing Service Providers | Registered Nurse | Obstetric, High-Risk |
ID Information
| ID | Type | State | Issuer | Description | 204419-0 | 01 | MN | REGISTERED NURSING LICENSE | OTHER |