Provider Demographics
NPI:1013095967
Name:HENDERSON, JULIE LYNN (RD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:LYNN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2812
Mailing Address - Country:US
Mailing Address - Phone:520-417-4994
Mailing Address - Fax:520-417-4994
Practice Address - Street 1:300 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2812
Practice Address - Country:US
Practice Address - Phone:520-417-4994
Practice Address - Fax:520-417-4994
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ836625133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ836625OtherCDR
AZ00836625OtherAMERICAN DIETETIC ASS.
AZ75714Medicare ID - Type UnspecifiedMEDICARE