Healthcare Provider Details

I. General information

NPI: 1104414713
Provider Name (Legal Business Name): KRISTIN HARDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-6211
  • Fax: 628-206-3242
Mailing address:
  • Phone: 628-206-6211
  • Fax: 628-206-3242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: