Provider Demographics
NPI:1083676613
Name:HENDERSON, HEATHER MARIE
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7574
Mailing Address - Country:US
Mailing Address - Phone:910-763-2476
Mailing Address - Fax:910-763-8176
Practice Address - Street 1:715 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7574
Practice Address - Country:US
Practice Address - Phone:910-763-2476
Practice Address - Fax:910-763-8176
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100148208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH31899Medicare UPIN