Provider Demographics
NPI:1699180810
Name:HENDERSON, AMELIA
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
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 1:3944 87TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-9516
Mailing Address - Country:US
Mailing Address - Phone:360-413-7602
Mailing Address - Fax:
Practice Address - Street 1:3944 87TH AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-9516
Practice Address - Country:US
Practice Address - Phone:360-413-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA385000310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility