Healthcare Provider Details

I. General information

NPI: 1699841379
Provider Name (Legal Business Name): MS. ANNETTA HARDIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 W LAWRENCE LN
GLENDALE AZ
85302-5229
US

IV. Provider business mailing address

4615 W LAWRENCE LN
GLENDALE AZ
85302-5229
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-5203
  • Fax:
Mailing address:
  • Phone: 623-334-5203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number11688
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: