Healthcare Provider Details

I. General information

NPI: 1700386125
Provider Name (Legal Business Name): DANIEL HENDRICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MIAMISBURG CENTERVILLE RD STE 207
MIAMISBURG OH
45342-3674
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B3
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-560-2011
  • Fax: 937-560-2012
Mailing address:
  • Phone: 937-991-3186
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.022092
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: