Healthcare Provider Details

I. General information

NPI: 1144137449
Provider Name (Legal Business Name): MACKENZIE SHARP PTA/ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MCMASTERS AVE
HANNIBAL MO
63401-2242
US

IV. Provider business mailing address

6500 HOSPITAL DR
HANNIBAL MO
63401-6890
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-2733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005146
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2020023326
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: