Provider Demographics
NPI:1760055008
Name:HENDERSON, SHAUNTELLE (LPN)
Entity Type:Individual
Prefix:
First Name:SHAUNTELLE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S JONES BLVD # 2440
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2623
Mailing Address - Country:US
Mailing Address - Phone:708-506-1536
Mailing Address - Fax:
Practice Address - Street 1:312 W 52ND PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-6229
Practice Address - Country:US
Practice Address - Phone:773-956-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.089473251J00000X, 164W00000X
305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251J00000XAgenciesNursing Care
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1215698527OtherAMOUR -PROPRE AESTHETE COLLECTIVE