Provider Demographics
NPI:1831138478
Name:HARDY-PETERSON, MARCELLA L (NP)
Entity Type:Individual
Prefix:MS
First Name:MARCELLA
Middle Name:L
Last Name:HARDY-PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3839
Mailing Address - Country:US
Mailing Address - Phone:909-881-7320
Mailing Address - Fax:909-881-7330
Practice Address - Street 1:742 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3839
Practice Address - Country:US
Practice Address - Phone:909-881-7320
Practice Address - Fax:909-881-7330
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5835363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ35980ZMedicaid
CAZZZ35980ZMedicaid