Provider Demographics
NPI:1407340730
Name:HENDERSON, MICHAEL JAMES (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2924
Mailing Address - Country:US
Mailing Address - Phone:509-897-3000
Mailing Address - Fax:
Practice Address - Street 1:380 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2924
Practice Address - Country:US
Practice Address - Phone:509-897-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60851799363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily