Provider Demographics
NPI:1124050059
Name:HENRICKSON, KATHI MARGARET
Entity type:Individual
Prefix:
First Name:KATHI
Middle Name:MARGARET
Last Name:HENRICKSON
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 1:2501 KEENAN DR
Mailing Address - Street 2:ESSENTIA HEALTH INTERNATIONAL FALLS CLINIC
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2181
Mailing Address - Country:US
Mailing Address - Phone:218-283-4481
Mailing Address - Fax:
Practice Address - Street 1:2501 KEENAN DR
Practice Address - Street 2:ESSENTIA HEALTH INTERNATIONAL FALLS CLINIC
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2181
Practice Address - Country:US
Practice Address - Phone:218-283-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-084037-0363LP0808X, 363LF0000X
MNCNP 2672363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN559177500Medicaid
WI41198600Medicaid
MN500003015Medicare ID - Type Unspecified
MN559177500Medicaid