Provider Demographics
NPI:1851837454
Name:HENDERSON, BREON MAREE (RNC, MSN, CLC)
Entity Type:Individual
Prefix:
First Name:BREON
Middle Name:MAREE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RNC, MSN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CYPRESS ST
Mailing Address - Street 2:STE D
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5411
Mailing Address - Country:US
Mailing Address - Phone:707-964-5696
Mailing Address - Fax:707-964-6274
Practice Address - Street 1:510 CYPRESS ST
Practice Address - Street 2:STE D
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5411
Practice Address - Country:US
Practice Address - Phone:707-964-5696
Practice Address - Fax:707-964-6274
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023758163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant