Provider Demographics
NPI:1891378741
Name:HENRIKSEN, LANDON PHILLIP
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:PHILLIP
Last Name:HENRIKSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E 1ST AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2344
Mailing Address - Country:US
Mailing Address - Phone:801-696-4261
Mailing Address - Fax:
Practice Address - Street 1:228 E 1ST AVE APT 7
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84103-2344
Practice Address - Country:US
Practice Address - Phone:801-696-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program