Provider Demographics
NPI:1437594520
Name:HENDERSON, NATASHA NICOLE (ARNP)
Entity Type:Individual
Prefix:MISS
First Name:NATASHA
Middle Name:NICOLE
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 1:15910 HUTTON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 SAINT JOHNS COMMONS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-4057
Practice Address - Country:US
Practice Address - Phone:904-824-9177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9205601363LF0000X
FLARNP9205601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008999000Medicaid
FLP01588097Medicare PIN
FLHJ336ZMedicare PIN