1043201304 NPI number — MRS. CHERYL LYNN HENDERSON FNP

Table of content: MRS. CHERYL LYNN HENDERSON FNP (NPI 1043201304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043201304 NPI number — MRS. CHERYL LYNN HENDERSON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
CHERYL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043201304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-324-6450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20208 STATE HIGHWAY 155 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75762-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-825-6222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  618206 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 75-2616977-028 . This is a "TRICARE LINDALE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 834N61 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-001 . This is a "TRICARE- CANTON" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 142475605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: TIN PLUS 002 . This is a "TRICARE LAKE PALESTINE LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00911377 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com