Healthcare Provider Details

I. General information

NPI: 1720601719
Provider Name (Legal Business Name): KATELYN HARDY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 05/25/2020
Certification Date: 05/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E RUSSELL AVE STE A
WARRENSBURG MO
64093-9601
US

IV. Provider business mailing address

23601 GOTTSCHALK RD
SEDALIA MO
65301-1581
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2020013200
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: