Provider Demographics
NPI:1144237389
Name:HARDY, THERESA E (ANP,IBCLC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:E
Last Name:HARDY
Suffix:
Gender:F
Credentials:ANP,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 W DANIEL ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4516
Mailing Address - Country:US
Mailing Address - Phone:217-552-1101
Mailing Address - Fax:888-965-5344
Practice Address - Street 1:1112 W DANIEL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-4516
Practice Address - Country:US
Practice Address - Phone:217-552-1101
Practice Address - Fax:888-965-5344
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL377000270363L00000X
IL277000270363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
433990OtherMEDICARE GROUP
L74193Medicare PIN
433990OtherMEDICARE GROUP