Provider Demographics
NPI:1285204057
Name:HENDERSON, RANDY LAVELLE JR (RN)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LAVELLE
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6606 COMANCHE POST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4760
Mailing Address - Country:US
Mailing Address - Phone:901-605-4833
Mailing Address - Fax:
Practice Address - Street 1:6606 COMANCHE POST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-4760
Practice Address - Country:US
Practice Address - Phone:901-605-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX940397163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse