Healthcare Provider Details

I. General information

NPI: 1518296375
Provider Name (Legal Business Name): TINA DENISE HENDRICKS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA DENISE GOODWIN RN

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 PARAGON PKWY SUITE 800
CLYDE NC
28721-9481
US

IV. Provider business mailing address

157 PARAGON PKWY SUITE 800
CLYDE NC
28721-9481
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-6675
  • Fax: 828-452-6730
Mailing address:
  • Phone: 828-452-6675
  • Fax: 828-452-6730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number235799
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: