Healthcare Provider Details

I. General information

NPI: 1619799665
Provider Name (Legal Business Name): REBECCA HENDRICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MEDICAL PARK DR
LEWISBURG PA
17837-6343
US

IV. Provider business mailing address

106 TRUMP RD
DANVILLE PA
17821-9319
US

V. Phone/Fax

Practice location:
  • Phone: 570-523-3264
  • Fax:
Mailing address:
  • Phone: 484-529-3349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP031142
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: