Provider Demographics
NPI:1881618163
Name:HENDERSON, MARY L (RNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4273
Mailing Address - Country:US
Mailing Address - Phone:503-399-2444
Mailing Address - Fax:503-581-3960
Practice Address - Street 1:1395 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4273
Practice Address - Country:US
Practice Address - Phone:503-399-2444
Practice Address - Fax:503-581-3960
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0750348367 WHCNP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000871Medicaid
OR000871Medicaid
OR115082Medicare PIN