Provider Demographics
NPI:1750027363
Name:HENDRICK, EMILY R (APRN)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:HENDRICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:R
Other - Last Name:VAN DEN BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-0454
Mailing Address - Fax:239-343-1075
Practice Address - Street 1:13778 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4301
Practice Address - Country:US
Practice Address - Phone:239-343-0454
Practice Address - Fax:239-343-1075
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006205363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114247700Medicaid