Healthcare Provider Details

I. General information

NPI: 1255197018
Provider Name (Legal Business Name): MIKENZIE HENDRICKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIKENZIE PARKER

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 W 200 S
KAMAS UT
84036-9010
US

IV. Provider business mailing address

948 W VAHE ST
DRAPER UT
84020-8416
US

V. Phone/Fax

Practice location:
  • Phone: 435-783-4385
  • Fax:
Mailing address:
  • Phone: 801-859-5939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13416827-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13416827-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: