Provider Demographics
NPI:1518478379
Name:HENDERSON, DELEICE (STNA)
Entity Type:Individual
Prefix:
First Name:DELEICE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2354 VICTORY AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-3544
Mailing Address - Country:US
Mailing Address - Phone:419-984-6221
Mailing Address - Fax:
Practice Address - Street 1:2354 VICTORY AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-3544
Practice Address - Country:US
Practice Address - Phone:419-984-6221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE