Provider Demographics
NPI:1417497074
Name:HARDISTER, MACKENZIE RAE (MHPP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:HARDISTER
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N HALL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1725
Mailing Address - Country:US
Mailing Address - Phone:214-533-9610
Mailing Address - Fax:
Practice Address - Street 1:2153 E JOYCE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5285
Practice Address - Country:US
Practice Address - Phone:479-575-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator