Healthcare Provider Details

I. General information

NPI: 1902535180
Provider Name (Legal Business Name): CHEYENNE LORIN HARDY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 LILLY RD NE
OLYMPIA WA
98506-5028
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-8880
  • Fax: 360-810-3697
Mailing address:
  • Phone: 239-432-8331
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPENDING
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61412070
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: