Provider Demographics
NPI:1245694140
Name:HENDERSON, VESTA LEE (RN)
Entity type:Individual
Prefix:MS
First Name:VESTA
Middle Name:LEE
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 1:346 BEACH PARK LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-5031
Mailing Address - Country:US
Mailing Address - Phone:207-253-9385
Mailing Address - Fax:
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2991522163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care