Provider Demographics
NPI:1083931968
Name:HENDRICKSON, SANDRA LEE (GERIATRIC NURSE PRAC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LEE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:GERIATRIC NURSE PRAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 FOREST RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4101
Mailing Address - Country:US
Mailing Address - Phone:831-236-5802
Mailing Address - Fax:
Practice Address - Street 1:1011 CASS ST STE 107
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4542
Practice Address - Country:US
Practice Address - Phone:831-324-0416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2242363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA147502OtherMEDICARE PTAN