Provider Demographics
NPI:1770112138
Name:HENDERSON, JUSTIN (NP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 120E
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-625-3640
Mailing Address - Fax:
Practice Address - Street 1:700 W IRONWOOD DR # 120E
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-625-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9132375-4405363LF0000X
ID68018363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily