MEDICARE: MR. GLENN A HARDESTY CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	ARNP9241242	FL

General Provider Information

NPI Number	:	1023013802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLENN A HARDESTY CRNA

Provider Business Mailing Address
First Line	:	383 ALPINE DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-9557
Country	:	US
Telephone Number	:	863-221-1813
Fax Number	:	863-294-5124

Provider Business Practice Location Address
First Line	:	383 ALPINE DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-9557
Country	:	US
Telephone Number	:	863-221-3718
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	06/06/2014

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