Provider Demographics
NPI:1467487645
Name:HENDERSON, STACY ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANNE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 SAND PIT RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4004
Mailing Address - Country:US
Mailing Address - Phone:203-798-6986
Mailing Address - Fax:
Practice Address - Street 1:69 SAND PIT RD
Practice Address - Street 2:SUITE 204
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4004
Practice Address - Country:US
Practice Address - Phone:203-798-6986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant