Basic Information
| Provider Information | |||||||||
| NPI: | 1376765842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDY | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648033810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173476843 | ||||||||
| FaxNumber: | 4173479397 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 W 32ND ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173474570 | ||||||||
| FaxNumber: | 4173476755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2011024757 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 2011024757 | MO | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 26887 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200252810A | 05 | OK | MEDICAID | 100747570A | 05 | OK | MEDICAID |