Provider Demographics
NPI:1720054620
Name:HENDERSON, ANN (CRNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 64620
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4620
Mailing Address - Country:US
Mailing Address - Phone:410-328-3037
Mailing Address - Fax:410-328-3040
Practice Address - Street 1:11065 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2998
Practice Address - Country:US
Practice Address - Phone:410-328-3037
Practice Address - Fax:410-328-3040
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR128848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR128848OtherMD BOARD OF NURSING LICEN
MDR173Medicare PIN
MDS99981Medicare UPIN