Basic Information
| Provider Information | |||||||||
| NPI: | 1255345336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENGLAND | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7707 PARAGON RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372086920 | ||||||||
| FaxNumber: | 9372086920 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 WAYNE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457503309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405682214 | ||||||||
| FaxNumber: | 7405682099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 03199 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 34.008678 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.