1518296375 NPI number — TINA DENISE HENDRICKS RN

Table of content: TINA DENISE HENDRICKS RN (NPI 1518296375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518296375 NPI number — TINA DENISE HENDRICKS RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKS
Provider First Name:
TINA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODWIN
Provider Other First Name:
TINA
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518296375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 PARAGON PKWY
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
CLYDE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28721-9481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-452-6675
Provider Business Mailing Address Fax Number:
828-452-6730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
157 PARAGON PKWY
Provider Second Line Business Practice Location Address:
SUITE 800
Provider Business Practice Location Address City Name:
CLYDE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28721-9481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-452-6675
Provider Business Practice Location Address Fax Number:
828-452-6730
Provider Enumeration Date:
12/08/2009

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: 163W00000X , with the licence number:  235799 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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