1871991893 NPI number — DR. EMILY ELISE HENDERSON MB BCH BAO

Table of content: DR. EMILY ELISE HENDERSON MB BCH BAO (NPI 1871991893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871991893 NPI number — DR. EMILY ELISE HENDERSON MB BCH BAO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
EMILY
Provider Middle Name:
ELISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MB BCH BAO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WAKELY
Provider Other First Name:
EMILY
Provider Other Middle Name:
ELISE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871991893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9505 S STEELE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98444-1858
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-597-6800
Provider Business Mailing Address Fax Number:
253-597-6888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9505 S STEELE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98444-1858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-597-6800
Provider Business Practice Location Address Fax Number:
253-597-6888
Provider Enumeration Date:
12/08/2014

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: 207RE0101X , with the licence number:  MD61023416 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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