Provider Demographics
NPI:1891091971
Name:HENDERSON, EMILIE M (CRNA)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:M
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:EMILIE
Other - Middle Name:M
Other - Last Name:WYBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:96022 OCEAN BREEZE WAY
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8489
Mailing Address - Country:US
Mailing Address - Phone:770-906-0029
Mailing Address - Fax:
Practice Address - Street 1:1250 S 18TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1902
Practice Address - Country:US
Practice Address - Phone:770-906-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2023-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9418490367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered