Provider Demographics
NPI:1740761949
Name:HENDERSON, ANITA CAMILLE
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:CAMILLE
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 1:718 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-2058
Mailing Address - Country:US
Mailing Address - Phone:931-801-0481
Mailing Address - Fax:
Practice Address - Street 1:718 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2058
Practice Address - Country:US
Practice Address - Phone:931-801-0481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist