Healthcare Provider Details

I. General information

NPI: 1891756193
Provider Name (Legal Business Name): MARYANN T HARDESTY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 E SHEA BLVD
PHOENIX AZ
85028-3074
US

IV. Provider business mailing address

3834 S SUNTREE WAY
BOISE ID
83706-6906
US

V. Phone/Fax

Practice location:
  • Phone: 602-464-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number272
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: