=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598625121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRAIG COLLIER MCHARDY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2025
-----------------------------------------------------
Last Update Date | 11/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2053 SE AVON PARK DR
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-7798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-201-2238
-----------------------------------------------------
Fax | 772-264-0103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2053 SE AVON PARK DR
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-7798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-201-2238
-----------------------------------------------------
Fax | 772-264-0103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 689409796
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------