Provider Demographics
NPI:1427481506
Name:HENDERSON, MICAH (DNP, FNP-BC)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:
Other - Last Name:GWALTNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-524-2273
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-524-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN0992015363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9195240OtherLICENSE
FL45681OtherMEDICARE - GROUP
COAPN0992015OtherLICENSE APN
FLHN217ZOtherMEDICARE - INDIVIDUAL
COAPN0992015OtherLICENSE APN