Provider Demographics
NPI:1407907157
Name:HENDERSON, MARTHA H (ARNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:H
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 OLYMPIA AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4033
Mailing Address - Country:US
Mailing Address - Phone:360-791-5933
Mailing Address - Fax:360-534-9169
Practice Address - Street 1:1005 OLYMPIA AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4033
Practice Address - Country:US
Practice Address - Phone:360-791-5933
Practice Address - Fax:360-534-9169
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005628363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1471HEOtherREGENCE RIDER
WA9629676Medicaid
WA9629676Medicaid
WAGAB39364Medicare PIN