Provider Demographics
NPI:1417240060
Name:HENDERSON, MICHELLE LEE (APN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-3517
Mailing Address - Country:US
Mailing Address - Phone:870-741-3252
Mailing Address - Fax:870-741-3962
Practice Address - Street 1:406 N WILLOW ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3517
Practice Address - Country:US
Practice Address - Phone:870-741-3252
Practice Address - Fax:870-741-3962
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03547 APN363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4A202F478OtherMEDICARE PTAN