Provider Demographics
NPI:1396135836
Name:HENDERSON, LISA (CRNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-6008
Mailing Address - Country:US
Mailing Address - Phone:215-322-0800
Mailing Address - Fax:215-322-2073
Practice Address - Street 1:729 GROVE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-6008
Practice Address - Country:US
Practice Address - Phone:215-322-0800
Practice Address - Fax:215-322-2073
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011196363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics