Provider Demographics
NPI:1790897031
Name:HENDERSON, KAREN J (RN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:J
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1978
Mailing Address - Country:US
Mailing Address - Phone:505-623-1480
Mailing Address - Fax:
Practice Address - Street 1:109 W BLAND ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5708
Practice Address - Country:US
Practice Address - Phone:505-623-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR21381163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77456581Medicaid