Provider Demographics
NPI:1740565290
Name:HENDERSON, LILLIE FAYE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:FAYE
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 1:18601 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-5915
Mailing Address - Country:US
Mailing Address - Phone:405-447-2532
Mailing Address - Fax:405-447-0878
Practice Address - Street 1:18601 CEDAR LN
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-5915
Practice Address - Country:US
Practice Address - Phone:405-447-2532
Practice Address - Fax:405-447-0878
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator