Provider Demographics
NPI:1376963041
Name:HARDY, LATONYA SIMONE (APN)
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:SIMONE
Last Name:HARDY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LATONYA
Other - Middle Name:SIMONE
Other - Last Name:HARDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:4165 PINE HILL CV N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-8111
Mailing Address - Country:US
Mailing Address - Phone:901-229-1787
Mailing Address - Fax:
Practice Address - Street 1:2747 BARTLETT BLVD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4580
Practice Address - Country:US
Practice Address - Phone:901-748-5308
Practice Address - Fax:901-529-7716
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000018640363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00477311Medicaid
TNQ021963Medicaid