Provider Demographics
NPI:1679867014
Name:HENDRICKS, AMANDA SUE (APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:HAYCRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1230 WOODLAND DR STE 211
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2792
Mailing Address - Country:US
Mailing Address - Phone:270-982-2500
Mailing Address - Fax:270-982-2501
Practice Address - Street 1:1230 WOODLAND DR STE 211
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2792
Practice Address - Country:US
Practice Address - Phone:270-982-2500
Practice Address - Fax:270-982-2501
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
12250853OtherCAQH
KY7100170880Medicaid