Provider Demographics
NPI:1184473555
Name:HENDERSON, ERICKA L
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:L
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 1:15073 PRIMROSE CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1634
Mailing Address - Country:US
Mailing Address - Phone:909-776-6775
Mailing Address - Fax:
Practice Address - Street 1:15073 PRIMROSE CT
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1634
Practice Address - Country:US
Practice Address - Phone:909-776-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB3639978172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver