Provider Demographics
NPI:1700539814
Name:HENDERSON, DENISE LATRICE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:LATRICE
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:PO BOX 15022
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46885-5022
Mailing Address - Country:US
Mailing Address - Phone:260-220-4961
Mailing Address - Fax:
Practice Address - Street 1:830 W STATE ST
Practice Address - Street 2:
Practice Address - City:ASHLEY
Practice Address - State:IN
Practice Address - Zip Code:46705-9767
Practice Address - Country:US
Practice Address - Phone:260-220-4961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)