Provider Demographics
NPI:1952013849
Name:HENSON, MIRANDA R (FNP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:R
Last Name:HENSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD STE 109N
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6148
Mailing Address - Country:US
Mailing Address - Phone:314-953-8799
Mailing Address - Fax:314-953-8798
Practice Address - Street 1:11155 DUNN RD STE 109N
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6148
Practice Address - Country:US
Practice Address - Phone:314-953-8799
Practice Address - Fax:314-953-8798
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022048278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner