Provider Demographics
NPI:1801293683
Name:BRANDY HENDERSON APRN LLC
Entity type:Organization
Organization Name:BRANDY HENDERSON APRN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:812-786-6639
Mailing Address - Street 1:15150 CRONEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:IN
Mailing Address - Zip Code:47143-9417
Mailing Address - Country:US
Mailing Address - Phone:812-786-6639
Mailing Address - Fax:
Practice Address - Street 1:15150 CRONEWOOD LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:IN
Practice Address - Zip Code:47143-9417
Practice Address - Country:US
Practice Address - Phone:812-786-6639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-22
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000909082OtherANTHEM
KY7100321840Medicaid
KY7100321840Medicaid