Provider Demographics
NPI:1588044655
Name:HENDRICKS, TINA (RN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:RED STAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:516 EPKARISCH
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:MT
Mailing Address - Zip Code:59066-0042
Mailing Address - Country:US
Mailing Address - Phone:406-638-3556
Mailing Address - Fax:
Practice Address - Street 1:10110 SOUTH 7650 EAST
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022-0009
Practice Address - Country:US
Practice Address - Phone:406-638-3556
Practice Address - Fax:406-638-3482
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT45662163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse