Healthcare Provider Details

I. General information

NPI: 1700387032
Provider Name (Legal Business Name): DEEDRA HARDRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 GA HIGHWAY 96
WARNER ROBINS GA
31088-2584
US

IV. Provider business mailing address

940 GA HIGHWAY 96
WARNER ROBINS GA
31088-2584
US

V. Phone/Fax

Practice location:
  • Phone: 478-662-9873
  • Fax: 478-988-8098
Mailing address:
  • Phone: 478-988-1222
  • Fax: 478-988-8098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: