Provider Demographics
NPI:1629522032
Name:HENDERSON FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:HENDERSON FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:TAYMAN
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:912-283-4422
Mailing Address - Street 1:403 LISTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5225
Mailing Address - Country:US
Mailing Address - Phone:912-283-4422
Mailing Address - Fax:912-283-4866
Practice Address - Street 1:403 LISTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5225
Practice Address - Country:US
Practice Address - Phone:912-283-4422
Practice Address - Fax:912-283-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN133742261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care