Provider Demographics
NPI:1417924358
Name:HENDERSON, SHERRI LEANN (PA C)
Entity type:Individual
Prefix:
First Name:SHERRI
Middle Name:LEANN
Last Name:HENDERSON
Suffix:
Gender:
Credentials:PA C
Other - Prefix:
Other - First Name:SHERRI
Other - Middle Name:LEANN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 N WICKHAM RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8663
Mailing Address - Country:US
Mailing Address - Phone:321-541-1777
Mailing Address - Fax:321-541-1788
Practice Address - Street 1:240 N WICKHAM RD STE 108
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8663
Practice Address - Country:US
Practice Address - Phone:321-841-1777
Practice Address - Fax:321-841-1788
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105795363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106506700Medicaid
OK200066220AMedicaid
P18939Medicare UPIN
OK200066220AMedicaid