Provider Demographics
NPI:1770795650
Name:HENRICKSEN, KATHY A (DPM)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:HENRICKSEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2793
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28106-2793
Mailing Address - Country:US
Mailing Address - Phone:704-841-4000
Mailing Address - Fax:704-841-4338
Practice Address - Street 1:512 E KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5118
Practice Address - Country:US
Practice Address - Phone:704-841-4000
Practice Address - Fax:704-841-4338
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC377213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2432917BMedicare ID - Type Unspecified
NCU60496Medicare UPIN