Provider Demographics
NPI:1265789853
Name:HENSON, AUTUMN NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
Last Name:HENSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:N
Other - Last Name:HENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:397 LITTLE NECK RD STE 120
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-5774
Mailing Address - Country:US
Mailing Address - Phone:757-395-1600
Mailing Address - Fax:
Practice Address - Street 1:397 LITTLE NECK RD STE 120
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-5774
Practice Address - Country:US
Practice Address - Phone:757-395-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182744363LF0000X
MO2012028199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1265789853Medicaid
MOP01106285OtherRR MCR
MO431560263OtherTRICARE
MO132300241Medicare PIN
MO1265789853Medicaid