Healthcare Provider Details

I. General information

NPI: 1205312790
Provider Name (Legal Business Name): KATHLEEN MARIE HENDRICKS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 W WILLOW KNOLLS DR
PEORIA IL
61614
US

IV. Provider business mailing address

2809 W WILLOW KNOLLS DR
PEORIA IL
61614-8517
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-6604
  • Fax:
Mailing address:
  • Phone: 309-692-6604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017970
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041.415297
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: