Provider Demographics
NPI:1093451007
Name:HENDERSON, STEPHANIE ANN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3224 OVAPA ROAD
Mailing Address - Street 2:
Mailing Address - City:PROCIOUS
Mailing Address - State:WV
Mailing Address - Zip Code:25164
Mailing Address - Country:US
Mailing Address - Phone:304-618-0378
Mailing Address - Fax:
Practice Address - Street 1:15 BANK STREET
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043
Practice Address - Country:US
Practice Address - Phone:304-587-9992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant