Provider Demographics
NPI:1609215151
Name:HENDERSON DREVECKY, LINDSEY LEE (MD)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:LEE
Last Name:HENDERSON DREVECKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 TACOMA AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-7452
Mailing Address - Country:US
Mailing Address - Phone:701-323-8961
Mailing Address - Fax:
Practice Address - Street 1:1040 TACOMA AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-7452
Practice Address - Country:US
Practice Address - Phone:701-323-8961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103265207Q00000X, 390200000X
ND14215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program