Provider Demographics
NPI:1649068610
Name:HENDERSON, MARANDA (LPN)
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:247 CIC BLVD
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-7512
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.191978164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115062Medicaid