Basic Information
Provider Information | |||||||||
NPI: | 1346667326 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDRICKSON | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SORENSEN | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 25317 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336225317 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132860033 | ||||||||
FaxNumber: | 8132821806 | ||||||||
Practice Location | |||||||||
Address1: | 5002 W LEMON ST | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336091104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8132860033 | ||||||||
FaxNumber: | 8132821806 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2014 | ||||||||
LastUpdateDate: | 10/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9288614 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 367A00000X | ARNP9288614 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | HT663Z | 01 | FL | MEDICARE | OTHER | 103326900 | 05 | FL |   | MEDICAID |