Provider Demographics
NPI:1427159854
Name:HENDERSON, MALINDA TERESA (APRN)
Entity type:Individual
Prefix:
First Name:MALINDA
Middle Name:TERESA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-3504
Mailing Address - Country:US
Mailing Address - Phone:507-931-7125
Mailing Address - Fax:507-931-7126
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-3504
Practice Address - Country:US
Practice Address - Phone:507-931-7125
Practice Address - Fax:507-931-7126
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR100511-4363LF0000X, 363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN32F26HEOtherBLUE CROSS / BLUE SHIELD
MN571822800Medicaid
MN500005162OtherRAILROAD PROVIDER #