Provider Demographics
NPI:1467832485
Name:HENDERSON, MARY ELLEN (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6640 GARTMAN RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-3722
Mailing Address - Country:US
Mailing Address - Phone:716-667-6818
Mailing Address - Fax:
Practice Address - Street 1:1038 DAVIS RD
Practice Address - Street 2:
Practice Address - City:WEST FALLS
Practice Address - State:NY
Practice Address - Zip Code:14170-9781
Practice Address - Country:US
Practice Address - Phone:716-655-8776
Practice Address - Fax:716-655-7877
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY362713 -1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse