Provider Demographics
NPI:1083364137
Name:HENDRICKSON, KRISTA (CNM)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:THURMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:442 W SALEM CANAL RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-9231
Mailing Address - Country:US
Mailing Address - Phone:801-234-9925
Mailing Address - Fax:
Practice Address - Street 1:527 W 400 N STE 4
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1951
Practice Address - Country:US
Practice Address - Phone:801-404-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7690389367A00000X
UT7690389-4402363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology