Provider Demographics
NPI:1215572763
Name:HENDERSON, SIMONE FAITH (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:FAITH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:FAITH
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COSMETOLOGIST
Mailing Address - Street 1:PO BOX 4552
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-0010
Mailing Address - Country:US
Mailing Address - Phone:917-834-1857
Mailing Address - Fax:
Practice Address - Street 1:11112 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3204
Practice Address - Country:US
Practice Address - Phone:917-834-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22WE11577583747P1801X
VA12011348893747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant