Healthcare Provider Details

I. General information

NPI: 1750914677
Provider Name (Legal Business Name): KATHERINE HENDRICKS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KASIE HENDRICKS

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 29TH ST SE
WATERTOWN SD
57201-9120
US

IV. Provider business mailing address

1509 7TH AVE NE
WATERTOWN SD
57201-5706
US

V. Phone/Fax

Practice location:
  • Phone: 605-753-0960
  • Fax:
Mailing address:
  • Phone: 605-237-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001702
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: