Provider Demographics
NPI:1508505330
Name:HENDERSON, TIA NICOLE
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:NICOLE
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 1:309 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-6723
Mailing Address - Country:US
Mailing Address - Phone:330-327-9128
Mailing Address - Fax:
Practice Address - Street 1:309 1ST ST SW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-6723
Practice Address - Country:US
Practice Address - Phone:330-327-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2023-07-29
Deactivation Date:2023-07-06
Deactivation Code:
Reactivation Date:2023-07-25
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7611294Medicaid