Provider Demographics
NPI:1740443084
Name:HENDERSON, LEANDRA R (APN)
Entity type:Individual
Prefix:
First Name:LEANDRA
Middle Name:R
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6034
Mailing Address - Country:US
Mailing Address - Phone:423-431-7047
Mailing Address - Fax:423-979-0569
Practice Address - Street 1:403 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6034
Practice Address - Country:US
Practice Address - Phone:423-431-7047
Practice Address - Fax:423-979-0569
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI0024172842363LP0808X
TN12527363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740443084Medicaid
TN1506060Medicaid
TN3341833Medicaid
TN600951198OtherMAGELLAN
TN3709285Medicare UPIN
TN600951198OtherMAGELLAN
TN103I502458Medicare PIN
TN10350I6030Medicare PIN
TN3341833Medicaid