MEDICARE: NOLA M HARDY RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	1991-029	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	963997	OTHER	WI	DIETETIC REGISTRATION

General Provider Information

NPI Number	:	1366586380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOLA M HARDY RD

Provider Business Mailing Address
First Line	:	781 OAK ST
Second Line	:	APT 8
City	:	PESHTIGO
State	:	WI
Zip	:	54157-1724
Country	:	US
Telephone Number	:	715-735-4609
Fax Number	:

Provider Business Practice Location Address
First Line	:	3130 SHORE DR
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-4291
Country	:	US
Telephone Number	:	715-735-7421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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