Provider Demographics
NPI:1841427978
Name:HENDERSON, MICHELLE REINA BOSLEY (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:REINA BOSLEY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 S 1200 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1524
Mailing Address - Country:US
Mailing Address - Phone:512-705-6161
Mailing Address - Fax:
Practice Address - Street 1:2000 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3208
Practice Address - Country:US
Practice Address - Phone:801-464-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8303357-1205208000000X, 2080P0203X
CODR.00564892080P0203X
TXBP10035444208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics