Provider Demographics
NPI:1902354467
Name:HARDMAN, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:HARDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11525 SW BEL AIRE LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5911
Mailing Address - Country:US
Mailing Address - Phone:971-770-5131
Mailing Address - Fax:
Practice Address - Street 1:11525 SW BEL AIRE LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-5911
Practice Address - Country:US
Practice Address - Phone:971-770-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22683172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty