Provider Demographics
NPI:1669450037
Name:HARDIN, CHARLIE M JR (CFNP/ACNP)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:M
Last Name:HARDIN
Suffix:JR
Gender:M
Credentials:CFNP/ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:110 PARK STREET
Practice Address - Street 2:
Practice Address - City:WALNUT GROVE
Practice Address - State:MS
Practice Address - Zip Code:39189
Practice Address - Country:US
Practice Address - Phone:601-253-0173
Practice Address - Fax:601-253-0176
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857156363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03239875Medicaid
P00151181OtherRAILROAD MEDICARE
500001530OtherPART B
500001530OtherPART B
MS03239875Medicaid