Provider Demographics
NPI:1366094310
Name:PONDER, HARLEY LAING
Entity type:Individual
Prefix:
First Name:HARLEY
Middle Name:LAING
Last Name:PONDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 SPRING HILL RD
Mailing Address - Street 2:
Mailing Address - City:WHIGHAM
Mailing Address - State:GA
Mailing Address - Zip Code:39897-2418
Mailing Address - Country:US
Mailing Address - Phone:229-327-4333
Mailing Address - Fax:
Practice Address - Street 1:1438 SPRING HILL RD
Practice Address - Street 2:
Practice Address - City:WHIGHAM
Practice Address - State:GA
Practice Address - Zip Code:39897-2418
Practice Address - Country:US
Practice Address - Phone:229-327-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer