Provider Demographics
NPI:1821254145
Name:NANINE S HENDERSON DO
Entity Type:Organization
Organization Name:NANINE S HENDERSON DO
Other - Org Name:NANINE S HENDERSON DO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NANINE
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-893-5422
Mailing Address - Street 1:4010 DUPONT CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4812
Mailing Address - Country:US
Mailing Address - Phone:502-893-5422
Mailing Address - Fax:502-896-4962
Practice Address - Street 1:4010 DUPONT CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4812
Practice Address - Country:US
Practice Address - Phone:502-893-5422
Practice Address - Fax:502-896-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1404201Medicare PIN