Provider Demographics
NPI:1770558249
Name:HENDRICKSON, KATHY MARIE (OD)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:MARIE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:CARRINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58421-2020
Mailing Address - Country:US
Mailing Address - Phone:701-652-2020
Mailing Address - Fax:701-652-2942
Practice Address - Street 1:110 9TH AVE S
Practice Address - Street 2:
Practice Address - City:CARRINGTON
Practice Address - State:ND
Practice Address - Zip Code:58421-2020
Practice Address - Country:US
Practice Address - Phone:701-652-2020
Practice Address - Fax:701-652-2942
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND578152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60529Medicaid
ND60529Medicaid