Provider Demographics
NPI:1497999643
Name:HENDERSON, LISA RESHAE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RESHAE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:RESHAE
Other - Last Name:FELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:814 N JOHN YOUNG PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4912
Mailing Address - Country:US
Mailing Address - Phone:407-816-0189
Mailing Address - Fax:407-870-1579
Practice Address - Street 1:814 N JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4912
Practice Address - Country:US
Practice Address - Phone:407-816-0189
Practice Address - Fax:407-870-1579
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2962412363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner