Provider Demographics
NPI:1104049691
Name:HENDERSON, SANDRA LEA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N WISCONSIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2034
Mailing Address - Country:US
Mailing Address - Phone:630-530-7776
Mailing Address - Fax:
Practice Address - Street 1:205 N WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2034
Practice Address - Country:US
Practice Address - Phone:630-530-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant