Provider Demographics
NPI:1306847686
Name:HENSON, ELAINE RUTH (ANP)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:RUTH
Last Name:HENSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MRS
Other - First Name:ELAINE
Other - Middle Name:RUTH
Other - Last Name:BROSIOUS-HENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:WRIGHT BUILDING, SUITE 410
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-779-9353
Mailing Address - Fax:
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:WRIGHT BUILDING, SUITE 410
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-779-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZNP54363L00000X
CA16376363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ500000021OtherRAILROAD MEDICARE
AZAZ0153580OtherBLUE CROSS BLUE SHIELD
AZ333253Medicaid
AZ333253Medicaid
AZ333253Medicaid