Provider Demographics
NPI:1720601719
Name:HARDY, KATELYN (OD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23601 GOTTSCHALK RD
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-1581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 E RUSSELL AVE STE A
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-9601
Practice Address - Country:US
Practice Address - Phone:660-747-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020013200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist