Provider Demographics
NPI:1801997606
Name:HENDERSON, TAMMY N (MD)
Entity type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:N
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMMY
Other - Middle Name:M
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9325C HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325-9219
Mailing Address - Country:US
Mailing Address - Phone:601-626-7108
Mailing Address - Fax:601-626-7975
Practice Address - Street 1:9325C HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39325-9219
Practice Address - Country:US
Practice Address - Phone:601-626-7108
Practice Address - Fax:601-626-7975
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13886208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS13886OtherMS LICENSE NUMBER
MS00121471Medicaid
MS13886OtherMS LICENSE NUMBER
MS080003194Medicare ID - Type UnspecifiedINACTIVE