Provider Demographics
NPI:1043880669
Name:HARDING, SHAYNA LARAE (APRN)
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:LARAE
Last Name:HARDING
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 1:652 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5103
Mailing Address - Country:US
Mailing Address - Phone:208-221-9992
Mailing Address - Fax:
Practice Address - Street 1:1133 CALL CREEK DR # A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3000
Practice Address - Country:US
Practice Address - Phone:208-232-1000
Practice Address - Fax:208-232-1006
Is Sole Proprietor?:No
Enumeration Date:2021-06-27
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine