Provider Demographics
NPI:1851090070
Name:HENSHAW, MAMIE RENE (PA-C)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:RENE
Last Name:HENSHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 WARWICK CREST LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-7360
Mailing Address - Country:US
Mailing Address - Phone:703-539-9838
Mailing Address - Fax:
Practice Address - Street 1:8616 WARWICK CREST LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-7360
Practice Address - Country:US
Practice Address - Phone:703-539-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant