Provider Demographics
NPI:1649459157
Name:HENDRIKS, DIANE (LPN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:HENDRIKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 STUYVESANT DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4251
Mailing Address - Country:US
Mailing Address - Phone:347-596-6027
Mailing Address - Fax:
Practice Address - Street 1:163 STUYVESANT DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-4251
Practice Address - Country:US
Practice Address - Phone:347-596-6027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2781571164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse