Provider Demographics
NPI:1659768562
Name:HENDERSON, TANYA DENISE
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:DENISE
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 1:132 PENNWOOD DR APT B
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2542
Mailing Address - Country:US
Mailing Address - Phone:585-419-5605
Mailing Address - Fax:
Practice Address - Street 1:132 PENNWOOD DR APT B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2542
Practice Address - Country:US
Practice Address - Phone:585-419-5605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318244-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse