Provider Demographics
NPI:1922486927
Name:HENDRICKSON, AMY NICOLE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301
Mailing Address - Country:US
Mailing Address - Phone:775-289-1640
Mailing Address - Fax:
Practice Address - Street 1:740 PARK AVE
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-2797
Practice Address - Country:US
Practice Address - Phone:775-289-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator