Provider Demographics
NPI:1164823506
Name:HARLAN, AUNDRYEA
Entity Type:Individual
Prefix:
First Name:AUNDRYEA
Middle Name:
Last Name:HARLAN
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 1:373 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-4421
Mailing Address - Country:US
Mailing Address - Phone:740-281-0908
Mailing Address - Fax:
Practice Address - Street 1:373 N 11TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-4421
Practice Address - Country:US
Practice Address - Phone:740-281-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 128276164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2958081Medicaid