Provider Demographics
NPI:1184350134
Name:HENDRICKS, DE'RICO (CAA)
Entity type:Individual
Prefix:
First Name:DE'RICO
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7919 COURTLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5930
Mailing Address - Country:US
Mailing Address - Phone:191-651-2991
Mailing Address - Fax:
Practice Address - Street 1:7919 COURTLEIGH DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5930
Practice Address - Country:US
Practice Address - Phone:191-651-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty