Provider Demographics
NPI:1871205369
Name:HANCOCK, MAKENNA LINDA
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:LINDA
Last Name:HANCOCK
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 1:99 W PALOMINO DR APT 156
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-7711
Mailing Address - Country:US
Mailing Address - Phone:605-680-4975
Mailing Address - Fax:
Practice Address - Street 1:225 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-7409
Practice Address - Country:US
Practice Address - Phone:602-888-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009101207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ009101OtherLICENSURE
2000027411OtherBOC CERTIFICATION