Provider Demographics
NPI:1023013802
Name:HARDESTY, GLENN A (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:A
Last Name:HARDESTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-9557
Mailing Address - Country:US
Mailing Address - Phone:863-221-1813
Mailing Address - Fax:863-294-5124
Practice Address - Street 1:383 ALPINE DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-9557
Practice Address - Country:US
Practice Address - Phone:863-221-3718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9241242367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered