Provider Demographics
NPI:1891170296
Name:HARDY, QUANISHA
Entity Type:Individual
Prefix:
First Name:QUANISHA
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HUMBOLDT ST
Mailing Address - Street 2:4G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-4138
Mailing Address - Country:US
Mailing Address - Phone:917-294-7380
Mailing Address - Fax:718-455-9037
Practice Address - Street 1:24 HUMBOLDT ST
Practice Address - Street 2:4G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4138
Practice Address - Country:US
Practice Address - Phone:917-294-7380
Practice Address - Fax:718-455-9037
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY539756383133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXV19664CMedicaid