Healthcare Provider Details

I. General information

NPI: 1659674356
Provider Name (Legal Business Name): TERANCE LEMONT HARDEMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2010
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 AMANDA DR
PEARL MS
39208-7009
US

IV. Provider business mailing address

125 AMANDA DR
PEARL MS
39208-7009
US

V. Phone/Fax

Practice location:
  • Phone: 601-331-1808
  • Fax: 601-825-6020
Mailing address:
  • Phone: 601-331-1808
  • Fax: 601-825-6020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR874872
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: