Provider Demographics
NPI:1316253115
Name:HENDERSON, CARON GIBSON (ANP)
Entity type:Individual
Prefix:
First Name:CARON
Middle Name:GIBSON
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:CARON
Other - Middle Name:CATHLEEN
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-0160
Mailing Address - Country:US
Mailing Address - Phone:601-394-2381
Mailing Address - Fax:601-394-5715
Practice Address - Street 1:1616 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-5622
Practice Address - Country:US
Practice Address - Phone:601-394-2381
Practice Address - Fax:601-394-5715
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873868363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09228250Medicaid