Provider Demographics
NPI:1578848594
Name:HENDRICKSON, TIMOTHY ALLEN (LPN-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:LPN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:IA
Mailing Address - Zip Code:51640-1345
Mailing Address - Country:US
Mailing Address - Phone:402-202-9830
Mailing Address - Fax:
Practice Address - Street 1:1305 BLUFF ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:IA
Practice Address - Zip Code:51640-1345
Practice Address - Country:US
Practice Address - Phone:402-202-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP36311164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse