Provider Demographics
NPI:1538708086
Name:HENDRICKS, ELLEN MICHELLE (APN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MICHELLE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:915 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62664-9708
Mailing Address - Country:US
Mailing Address - Phone:309-638-2427
Mailing Address - Fax:
Practice Address - Street 1:915 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IL
Practice Address - Zip Code:62664-9708
Practice Address - Country:US
Practice Address - Phone:309-638-2427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily