Provider Demographics
NPI:1003369190
Name:HENDERSON, DAVID LANCE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LANCE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6569 CODELL ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8128
Mailing Address - Country:US
Mailing Address - Phone:850-240-8578
Mailing Address - Fax:
Practice Address - Street 1:91 BAY BRIDGE DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4468
Practice Address - Country:US
Practice Address - Phone:850-418-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion