Provider Demographics
NPI:1841285145
Name:HENDERSON, SUSAN (FNP-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 W HIGH ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-3971
Mailing Address - Country:US
Mailing Address - Phone:419-227-5298
Mailing Address - Fax:419-227-5879
Practice Address - Street 1:830 W HIGH ST
Practice Address - Street 2:SUITE 307
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3971
Practice Address - Country:US
Practice Address - Phone:419-227-5298
Practice Address - Fax:419-227-5879
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP05563363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2189199Medicaid
OHHENP10321Medicare ID - Type Unspecified
OH2189199Medicaid