Provider Demographics
NPI:1083496442
Name:HENDERSON, TERESA ROSE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ROSE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1064
Mailing Address - Country:US
Mailing Address - Phone:617-855-2356
Mailing Address - Fax:
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1064
Practice Address - Country:US
Practice Address - Phone:617-855-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN262715363L00000X, 163WP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health