Provider Demographics
NPI:1508196718
Name:HENKELS, TIMOTHY W (ANP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:W
Last Name:HENKELS
Suffix:
Gender:M
Credentials:ANP
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 320
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380
Mailing Address - Country:US
Mailing Address - Phone:541-444-1030
Mailing Address - Fax:541-444-9695
Practice Address - Street 1:200 GWEE SHUT ROAD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380
Practice Address - Country:US
Practice Address - Phone:541-444-1030
Practice Address - Fax:541-444-9695
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01516363L00000X
AZAP7919363LA2200X
UT9171990-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner