Provider Demographics
NPI:1699879239
Name:HENDRIX, BERTHA LEE (OGNP)
Entity type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:LEE
Last Name:HENDRIX
Suffix:
Gender:F
Credentials:OGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 PLEASANT OAK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5930
Mailing Address - Country:US
Mailing Address - Phone:910-868-6171
Mailing Address - Fax:910-433-3701
Practice Address - Street 1:227 FOUNTAINHEAD LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5417
Practice Address - Country:US
Practice Address - Phone:910-433-3647
Practice Address - Fax:910-433-3701
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC80575363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZF5096Medicare UPIN
2596394Medicare ID - Type Unspecified