Provider Demographics
NPI:1902416233
Name:HARDISTY, AJA DANIELLE (FNP-BC, AGACNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:AJA
Middle Name:DANIELLE
Last Name:HARDISTY
Suffix:
Gender:F
Credentials:FNP-BC, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 PROFESSIONAL PL STE 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-8125
Mailing Address - Country:US
Mailing Address - Phone:719-260-1161
Mailing Address - Fax:719-362-1103
Practice Address - Street 1:8653 ALPINE VALLEY DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7310
Practice Address - Country:US
Practice Address - Phone:719-225-0593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0995939363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner