Healthcare Provider Details

I. General information

NPI: 1174902134
Provider Name (Legal Business Name): PAMELA DENISE HARDIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2015
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 MAGNOLIA DR
RALEIGH MS
39153-6012
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-782-5665
  • Fax:
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR882719
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: