Provider Demographics
NPI:1679219794
Name:HENDRICKSON, EMILY ANN
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MERCY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-725-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2024-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0101279637208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider