Provider Demographics
NPI:1396108189
Name:HARDESTY, CHELSEA
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:HARDESTY
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 1:4646 BROCKTON AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0172
Mailing Address - Country:US
Mailing Address - Phone:951-686-7600
Mailing Address - Fax:951-369-9999
Practice Address - Street 1:4646 BROCKTON AVE STE 302
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0172
Practice Address - Country:US
Practice Address - Phone:951-686-7600
Practice Address - Fax:951-369-9999
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant