Provider Demographics
NPI:1093113797
Name:HERNDON, CHRISEANA
Entity Type:Individual
Prefix:
First Name:CHRISEANA
Middle Name:
Last Name:HERNDON
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 1:9445 MANISTIQUE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2864
Mailing Address - Country:US
Mailing Address - Phone:313-348-6988
Mailing Address - Fax:
Practice Address - Street 1:9445 MANISTIQUE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2864
Practice Address - Country:US
Practice Address - Phone:313-348-6988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703105966164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse