Provider Demographics
NPI:1891159927
Name:HENDERSON, DEIDRA (RN)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:APACHE
Mailing Address - State:OK
Mailing Address - Zip Code:73006-0224
Mailing Address - Country:US
Mailing Address - Phone:580-450-3257
Mailing Address - Fax:580-588-2289
Practice Address - Street 1:48025 COUNTY STREET 2580
Practice Address - Street 2:
Practice Address - City:APACHE
Practice Address - State:OK
Practice Address - Zip Code:73006-9708
Practice Address - Country:US
Practice Address - Phone:580-450-3257
Practice Address - Fax:580-588-2289
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0074963163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse