Provider Demographics
NPI:1093487407
Name:HENDERSON, STEPHANIE TERRELL (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:TERRELL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 REVOLUTION DR
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1086
Mailing Address - Country:US
Mailing Address - Phone:252-342-5772
Mailing Address - Fax:
Practice Address - Street 1:313 REVOLUTION DR
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1086
Practice Address - Country:US
Practice Address - Phone:252-342-5772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant