Provider Demographics
NPI:1043201304
Name:HENDERSON, CHERYL LYNN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LYNN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:20208 STATE HIGHWAY 155 S
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:TX
Practice Address - Zip Code:75762-5600
Practice Address - Country:US
Practice Address - Phone:903-825-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-028OtherTRICARE LINDALE
TX834N61OtherBCBS
TX75-2616977-001OtherTRICARE- CANTON
TX142475605Medicaid
TXTIN PLUS 002OtherTRICARE LAKE PALESTINE LOCATION
TXP00911377OtherMEDICARE RAILROAD
TX142475605Medicaid
TX142475605Medicaid