Provider Demographics
NPI:1699841379
Name:HARDIN, ANNETTA
Entity Type:Individual
Prefix:MS
First Name:ANNETTA
Middle Name:
Last Name:HARDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 W LAWRENCE LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-5229
Mailing Address - Country:US
Mailing Address - Phone:623-334-5203
Mailing Address - Fax:
Practice Address - Street 1:4615 W LAWRENCE LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5229
Practice Address - Country:US
Practice Address - Phone:623-334-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11688385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ132419OtherAHCCCS ID NUMBER