Provider Demographics
NPI:1477029015
Name:HENDERSON, MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
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 1:424 MAPLE ST SW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-3121
Mailing Address - Country:US
Mailing Address - Phone:386-209-7649
Mailing Address - Fax:386-219-0222
Practice Address - Street 1:100 COURT ST SE STE 212
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3203
Practice Address - Country:US
Practice Address - Phone:386-209-7649
Practice Address - Fax:386-219-0222
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No251E00000XAgenciesHome Health
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care