Provider Demographics
NPI:1275312878
Name:HENDERSON, MISTY S
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:S
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:S
Other - Last Name:TRUAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 SAND MINE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-7457
Mailing Address - Country:US
Mailing Address - Phone:304-258-3096
Mailing Address - Fax:
Practice Address - Street 1:106 SAND MINE RD STE 1
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-7457
Practice Address - Country:US
Practice Address - Phone:304-258-3096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant