Provider Demographics
NPI:1033801121
Name:HENDRICKS, KHAMRYN JEANETTE
Entity Type:Individual
Prefix:MS
First Name:KHAMRYN
Middle Name:JEANETTE
Last Name:HENDRICKS
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 1:2640 CRIMSON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3491
Mailing Address - Country:US
Mailing Address - Phone:618-960-1526
Mailing Address - Fax:
Practice Address - Street 1:1021 W E ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1055
Practice Address - Country:US
Practice Address - Phone:618-233-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant