Provider Demographics
NPI:1063266062
Name:HENDERSON, DEMETRIA ANTOINETE (CNA)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:ANTOINETE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 PIEDMONT AVE NE UNIT 55583
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-8719
Mailing Address - Country:US
Mailing Address - Phone:615-500-5600
Mailing Address - Fax:
Practice Address - Street 1:570 PIEDMONT AVE NE UNIT 55583
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-8719
Practice Address - Country:US
Practice Address - Phone:615-500-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030092062376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide