MEDICARE: MS. DIANE HENDRIKS LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	2781571	NY

General Provider Information

NPI Number	:	1649459157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE HENDRIKS LPN

Provider Business Mailing Address
First Line	:	163 STUYVESANT DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-4251
Country	:	US
Telephone Number	:	347-596-6027
Fax Number	:

Provider Business Practice Location Address
First Line	:	163 STUYVESANT DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-4251
Country	:	US
Telephone Number	:	347-596-6027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2007
Last Update Date	:	10/14/2014

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