Provider Demographics
NPI:1821345471
Name:HENDERSON, ANGELIA D
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:D
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 1:5708 N 167TH AVE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116
Mailing Address - Country:US
Mailing Address - Phone:402-681-9469
Mailing Address - Fax:
Practice Address - Street 1:2525 S. 135TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144
Practice Address - Country:US
Practice Address - Phone:402-333-2304
Practice Address - Fax:402-333-1269
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE324314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility