Provider Demographics
NPI:1770813925
Name:HENDERSON, GRACE ALICIA (RN)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:ALICIA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N CASS ST
Mailing Address - Street 2:APT. #362
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3374
Mailing Address - Country:US
Mailing Address - Phone:815-505-4209
Mailing Address - Fax:
Practice Address - Street 1:1007 N CASS ST
Practice Address - Street 2:APT. #362
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3374
Practice Address - Country:US
Practice Address - Phone:815-505-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164595-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse