Provider Demographics
NPI:1700758000
Name:HENDRICKSON, LISA M (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-2055
Mailing Address - Country:US
Mailing Address - Phone:607-382-6972
Mailing Address - Fax:
Practice Address - Street 1:4612 MILLENNIUM DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-1197
Practice Address - Country:US
Practice Address - Phone:607-737-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY533054-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161039939Medicaid
NY161039939Other161039939