Provider Demographics
NPI:1275286965
Name:HENDERSON, TIESHA SHANAY (RN)
Entity Type:Individual
Prefix:
First Name:TIESHA
Middle Name:SHANAY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 FROWEIN RD
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-1921
Mailing Address - Country:US
Mailing Address - Phone:631-902-6468
Mailing Address - Fax:
Practice Address - Street 1:179 FROWEIN RD
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-1921
Practice Address - Country:US
Practice Address - Phone:631-902-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY813137-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse