Provider Demographics
NPI:1538719315
Name:HENDRICKSON, KELLY MCPHERSON (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MCPHERSON
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 PINEBLUFF RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4729
Mailing Address - Country:US
Mailing Address - Phone:910-625-7306
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC129122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered