Provider Demographics
NPI:1093774754
Name:HENDRICKSON, KATHRYN DENISE (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DENISE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11017
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1017
Mailing Address - Country:US
Mailing Address - Phone:479-478-7200
Mailing Address - Fax:478-478-7225
Practice Address - Street 1:7303 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4112
Practice Address - Country:US
Practice Address - Phone:479-478-7200
Practice Address - Fax:478-478-7225
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7631208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
17654000000OtherQUALCHOICE
AR53126OtherBLUE CROSS & BLUE SHIELD
1625759OtherCIGNA
17654000000OtherQUALCHOICE
1625759OtherCIGNA