Provider Demographics
NPI:1821499153
Name:HENDERSON, AMY (RD, MS, LD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RD, MS, LD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:RUSKOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5662 S 83RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-7922
Mailing Address - Country:US
Mailing Address - Phone:918-902-5611
Mailing Address - Fax:
Practice Address - Street 1:10306 N 138TH EAST AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4665
Practice Address - Country:US
Practice Address - Phone:918-401-0006
Practice Address - Fax:877-380-4628
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1719133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered