1215325105 NPI number — SHELLEY ELAINE HENDERSON MSN, RN, APRN

Table of content: SHELLEY ELAINE HENDERSON MSN, RN, APRN (NPI 1215325105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215325105 NPI number — SHELLEY ELAINE HENDERSON MSN, RN, APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
SHELLEY
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MENDRICK
Provider Other First Name:
SHELLEY
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215325105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8193 MALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-925-4733
Provider Business Mailing Address Fax Number:
859-525-0173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8193 MALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-925-4733
Provider Business Practice Location Address Fax Number:
859-525-0173
Provider Enumeration Date:
12/31/2014

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: 363LF0000X , with the licence number:  COA.17912-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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