Provider Demographics
NPI:1689365736
Name:HENDRICKSON, TAMARA JOY (ABO, NCLE)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:JOY
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:ABO, NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11505 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4239
Mailing Address - Country:US
Mailing Address - Phone:763-354-5399
Mailing Address - Fax:763-862-8742
Practice Address - Street 1:11505 ULYSSES ST NE # B
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4239
Practice Address - Country:US
Practice Address - Phone:763-354-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician