Provider Demographics
NPI:1720293277
Name:HENDRICKS, GLENMORE (NP)
Entity Type:Individual
Prefix:
First Name:GLENMORE
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12742 LIMONITE AVE
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-9630
Mailing Address - Country:US
Mailing Address - Phone:951-782-2731
Mailing Address - Fax:
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-782-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 14239363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner