Provider Demographics
NPI:1366576563
Name:HARDIE, MICHELLE LYNN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:HARDIE
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:PO BOX 3128
Mailing Address - Street 2:STE 410
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102
Mailing Address - Country:US
Mailing Address - Phone:712-239-4702
Mailing Address - Fax:712-239-0616
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:STE 410
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51102
Practice Address - Country:US
Practice Address - Phone:712-239-4702
Practice Address - Fax:712-239-0616
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001478363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical