Provider Demographics
NPI:1891233441
Name:HENDERSON, AYANA
Entity Type:Individual
Prefix:
First Name:AYANA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 LESTER RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-1505
Mailing Address - Country:US
Mailing Address - Phone:857-206-7619
Mailing Address - Fax:617-425-2081
Practice Address - Street 1:1601 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1951
Practice Address - Country:US
Practice Address - Phone:857-206-7619
Practice Address - Fax:617-425-2081
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker