Provider Demographics
NPI:1467151563
Name:HENDERSON, LATOYA L
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 JEROME BLVD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-3066
Mailing Address - Country:US
Mailing Address - Phone:262-822-5298
Mailing Address - Fax:
Practice Address - Street 1:2224 JEROME BLVD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-3066
Practice Address - Country:US
Practice Address - Phone:262-822-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0019058251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health