Healthcare Provider Details

I. General information

NPI: 1497419626
Provider Name (Legal Business Name): CARLY ANN HENDRICKS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE, ML 11027
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-517-2234
  • Fax: 513-803-1969
Mailing address:
  • Phone: 553-636-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0035261
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number529290
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: