Provider Demographics
NPI:1639106453
Name:HARDY, DALE A (CNM)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:HARDY
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:#217
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5937
Mailing Address - Country:US
Mailing Address - Phone:907-456-8191
Mailing Address - Fax:907-456-8192
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:#217
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-456-8191
Practice Address - Fax:907-456-8192
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT203233-4402207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057973Medicare ID - Type Unspecified
UTD3728Medicare UPIN