Provider Demographics
NPI:1881643237
Name:HENDERSON, NANCY ANN (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-220-7270
Practice Address - Fax:864-220-7290
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC160652080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC160658Medicaid
SC160658Medicaid
SCA993837951Medicare PIN
SC160658Medicaid
SCA993837951Medicare PIN
SCA993833640Medicare PIN
SC2774538OtherCIGNA
SC5905778OtherAETNA