Provider Demographics
NPI:1336373240
Name:HENSON MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:HENSON MEDICAL CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:228-864-0622
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-0609
Mailing Address - Country:US
Mailing Address - Phone:228-864-0622
Mailing Address - Fax:228-864-7958
Practice Address - Street 1:200 W RAILROAD ST
Practice Address - Street 2:104
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4517
Practice Address - Country:US
Practice Address - Phone:228-864-0622
Practice Address - Fax:228-864-7958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR518328363LF0000X
MSR862256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty