Provider Demographics
NPI:1952636185
Name:HENDERSON, MELISSA MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MARIE
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 1:77 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5226
Mailing Address - Country:US
Mailing Address - Phone:845-741-7060
Mailing Address - Fax:
Practice Address - Street 1:77 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-5226
Practice Address - Country:US
Practice Address - Phone:845-741-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY542690-1163W00000X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0200XNursing Service ProvidersRegistered NursePediatrics