Provider Demographics
NPI:1255694998
Name:HENDERSON, STEPHEN TODD (FNP)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TODD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:EVADALE
Mailing Address - State:TX
Mailing Address - Zip Code:77615-1086
Mailing Address - Country:US
Mailing Address - Phone:409-289-4582
Mailing Address - Fax:
Practice Address - Street 1:6510 FOLSOM DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7274
Practice Address - Country:US
Practice Address - Phone:409-832-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily