1720054620 NPI number — ANN HENDERSON CRNP

Table of content: ANN HENDERSON CRNP (NPI 1720054620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720054620 NPI number — ANN HENDERSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
ANN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDERSON
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720054620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64620
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21264-4620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-328-3037
Provider Business Mailing Address Fax Number:
410-328-3040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11065 LITTLE PATUXENT PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044-2998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-3037
Provider Business Practice Location Address Fax Number:
410-328-3040
Provider Enumeration Date:
02/28/2006

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: 363L00000X , with the licence number:  R128848 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R128848 . This is a "MD BOARD OF NURSING LICEN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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