Provider Demographics
NPI:1225386345
Name:HENRIKSON, TARA DEDIC (APN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DEDIC
Last Name:HENRIKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 SOUTH 1ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:MAYOOWD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:
Practice Address - Street 1:250 E SUPERIOR ST STE 4-420
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2914
Practice Address - Country:US
Practice Address - Phone:312-695-0990
Practice Address - Fax:312-472-4784
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041347688163WX0200X
IL209009963363L00000X
IL209.009963363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WX0200XNursing Service ProvidersRegistered NurseOncology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner