Provider Demographics
NPI:1275033938
Name:HENDERSON, OPAL MARIE X
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:MARIE
Last Name:HENDERSON
Suffix:X
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 1:2311 INMAN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-7917
Mailing Address - Country:US
Mailing Address - Phone:903-578-7106
Mailing Address - Fax:
Practice Address - Street 1:2311 INMAN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-7917
Practice Address - Country:US
Practice Address - Phone:903-578-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122783164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse