Provider Demographics
NPI:1699014746
Name:HENDERSON, DEWANNA (PA-C, BA)
Entity Type:Individual
Prefix:
First Name:DEWANNA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PA-C, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 LEBANON RD
Mailing Address - Street 2:STE 144-425
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-7260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 S BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7310
Practice Address - Country:US
Practice Address - Phone:865-685-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-10
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2315363A00000X
TX106E00000X
GA7034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant