Provider Demographics
NPI:1750479838
Name:HARDY, STEPHANIE RENAE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:RENAE
Last Name:HARDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:CORTESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-0867
Mailing Address - Country:US
Mailing Address - Phone:910-754-2020
Mailing Address - Fax:910-754-8811
Practice Address - Street 1:4830 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-1863
Practice Address - Country:US
Practice Address - Phone:910-754-2020
Practice Address - Fax:910-754-8811
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC2164AOtherMEDICARE PTAN
NC5909229Medicaid