Provider Demographics
NPI:1508122011
Name:HENRICKSON, KOURTNEY CHRISTIN (LPN)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:CHRISTIN
Last Name:HENRICKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KOURTNEY
Other - Middle Name:CHRISTIN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1946 30TH ST
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-2022
Mailing Address - Country:US
Mailing Address - Phone:920-905-3307
Mailing Address - Fax:
Practice Address - Street 1:1946 30TH ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-2022
Practice Address - Country:US
Practice Address - Phone:920-905-3307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314450-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse