Healthcare Provider Details

I. General information

NPI: 1114424546
Provider Name (Legal Business Name): MICHELLE HARDIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 GUM BRANCH RD STE 600
JACKSONVILLE NC
28540-4008
US

IV. Provider business mailing address

106 CHRISTY DR
BEULAVILLE NC
28518-7711
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-9800
  • Fax: 910-455-2083
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6734
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: