Provider Demographics
NPI:1720524390
Name:HENDERSON, RAEANN
Entity Type:Individual
Prefix:
First Name:RAEANN
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 1:3510 SWAFFER RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48746-9055
Mailing Address - Country:US
Mailing Address - Phone:989-871-6274
Mailing Address - Fax:
Practice Address - Street 1:3510 SWAFFER RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:MI
Practice Address - Zip Code:48746-9055
Practice Address - Country:US
Practice Address - Phone:989-871-6274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH536730603065390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program