Provider Demographics
NPI:1912442179
Name:HENDERSON, TARI RENEE (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:TARI
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 1:11100 EUCLID AVE
Mailing Address - Street 2:MEDICINE/CARDIOLIGY LEARNER 3
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-983-4900
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:MEDICINE/CARDIOLOGY LEARNER 3
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-983-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAG1116006363LA2200X, 363LP2300X
OHAG111006363LG0600X
OHCNP-020426363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care