Provider Demographics
NPI:1164794319
Name:HENDERSON, NINA
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORNELIA
Other - Middle Name:
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8908 PICKET FENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-1114
Mailing Address - Country:US
Mailing Address - Phone:702-476-3909
Mailing Address - Fax:
Practice Address - Street 1:8908 PICKET FENCE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89143-1114
Practice Address - Country:US
Practice Address - Phone:702-476-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner