Provider Demographics
NPI:1427305408
Name:HENDRICKSON, REBECCA E (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE STE 205
Mailing Address - Street 2:PROHEALTH CARE DIABETES CENTER
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-4695
Mailing Address - Fax:
Practice Address - Street 1:721 AMERICAN AVE STE 205
Practice Address - Street 2:PROHEALTH CARE DIABETES CENTER
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI161545163W00000X
WI4966363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
68375Medicare PIN