Provider Demographics
NPI:1598087371
Name:HARDY, MIRNA
Entity Type:Individual
Prefix:MISS
First Name:MIRNA
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRNA
Other - Middle Name:
Other - Last Name:BOTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4324
Mailing Address - Country:US
Mailing Address - Phone:650-573-4733
Mailing Address - Fax:
Practice Address - Street 1:225 37TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403
Practice Address - Country:US
Practice Address - Phone:650-573-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator