Provider Demographics
NPI:1396358883
Name:HENDRICKSON, SUDIAN KERRIAN
Entity Type:Individual
Prefix:
First Name:SUDIAN
Middle Name:KERRIAN
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19827 SW 118TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-4445
Mailing Address - Country:US
Mailing Address - Phone:305-984-6697
Mailing Address - Fax:
Practice Address - Street 1:975 BAPTIST WAY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7600
Practice Address - Country:US
Practice Address - Phone:305-779-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily