Provider Demographics
NPI:1619554441
Name:HENDERSON, TYRA L
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:L
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 1:4521 S EDGE RD
Mailing Address - Street 2:
Mailing Address - City:AYDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28513-7119
Mailing Address - Country:US
Mailing Address - Phone:252-864-1096
Mailing Address - Fax:252-304-2103
Practice Address - Street 1:4521 S EDGE RD
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513-7119
Practice Address - Country:US
Practice Address - Phone:252-864-1096
Practice Address - Fax:252-304-2103
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health