Provider Demographics
NPI:1043356827
Name:HENRIQUEZ, KAREN (OTC)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:
Last Name:HENRIQUEZ
Suffix:
Gender:F
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 E ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5580
Mailing Address - Country:US
Mailing Address - Phone:209-572-3224
Mailing Address - Fax:209-572-4528
Practice Address - Street 1:609 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5580
Practice Address - Country:US
Practice Address - Phone:209-572-3224
Practice Address - Fax:209-572-4528
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-0161247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other