Provider Demographics
NPI:1659090348
Name:HENDRICKS, TIA LYANN (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:TIA
Middle Name:LYANN
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:LYANN
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:534 MAPLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1981
Mailing Address - Country:US
Mailing Address - Phone:573-760-8253
Mailing Address - Fax:
Practice Address - Street 1:534 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1981
Practice Address - Country:US
Practice Address - Phone:573-760-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022026226363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner