Provider Demographics
NPI:1396409603
Name:HENDERSON, KERI (LVN)
Entity Type:Individual
Prefix:MRS
First Name:KERI
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 N UNIVERSITY DR APT 214
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2608
Mailing Address - Country:US
Mailing Address - Phone:936-205-8897
Mailing Address - Fax:
Practice Address - Street 1:216 N JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-2620
Practice Address - Country:US
Practice Address - Phone:936-261-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX199802164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse