Provider Demographics
NPI:1023808094
Name:HENDERSON, MARY GRACE ELIZABETH (RN)
Entity type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:ELIZABETH
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 1:3546 SANDY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4054
Mailing Address - Country:US
Mailing Address - Phone:770-625-0810
Mailing Address - Fax:
Practice Address - Street 1:2220 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3117
Practice Address - Country:US
Practice Address - Phone:404-785-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN308389163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine