Provider Demographics
NPI:1417836677
Name:HENDERSON, TANIA
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 188TH ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3402
Mailing Address - Country:US
Mailing Address - Phone:708-263-9115
Mailing Address - Fax:
Practice Address - Street 1:701 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4037
Practice Address - Country:US
Practice Address - Phone:219-922-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-30
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041497982163W00000X
IN28262477A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse