Provider Demographics
NPI:1336901875
Name:HENDERSON, TIESHA BINGHAM (NP)
Entity Type:Individual
Prefix:MRS
First Name:TIESHA
Middle Name:BINGHAM
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GREVILLEA CT
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-6033
Mailing Address - Country:US
Mailing Address - Phone:251-610-0613
Mailing Address - Fax:
Practice Address - Street 1:3 GREVILLEA CT
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-6033
Practice Address - Country:US
Practice Address - Phone:251-610-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN276830363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health