Provider Demographics
NPI:1295064574
Name:HENDRICKSON, STACI DIANE (RD)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:DIANE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 N 1851ST DIAG RD
Mailing Address - Street 2:
Mailing Address - City:LECOMPTON
Mailing Address - State:KS
Mailing Address - Zip Code:66050-4114
Mailing Address - Country:US
Mailing Address - Phone:785-760-4501
Mailing Address - Fax:785-727-1805
Practice Address - Street 1:4930 OVERLAND DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4132
Practice Address - Country:US
Practice Address - Phone:785-760-4501
Practice Address - Fax:785-727-1805
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS000947133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered