1992256796 NPI number — MS. MARYALICE RENATE HARDISON ARNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992256796 NPI number — MS. MARYALICE RENATE HARDISON ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDISON
Provider First Name:
MARYALICE
Provider Middle Name:
RENATE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992256796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 FORT ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPPENISH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-314-6090
Provider Business Mailing Address Fax Number:
509-219-3003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 S ALDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPPENISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98948-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-314-6090
Provider Business Practice Location Address Fax Number:
509-219-3003
Provider Enumeration Date:
10/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  AP60712802 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: AP60712802 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13943718 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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