Provider Demographics
NPI:1013984608
Name:HENDERSON, MARIE C (CNM)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIANS ORGANIZATION INC
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:YAW 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-724-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA171364367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACN0243OtherBS
MA0377741Medicaid
P25376Medicare UPIN
MA0377741Medicaid