Provider Demographics
NPI:1912419243
Name:HENDERSON, LISA RENEE (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:208-750-7445
Mailing Address - Fax:
Practice Address - Street 1:415 SIXTH ST.
Practice Address - Street 2:CARDIOLOGY DEPARTMENT
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4255
Practice Address - Country:US
Practice Address - Phone:208-750-7507
Practice Address - Fax:208-750-7384
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57109363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner