Provider Demographics
NPI:1487711586
Name:HENDERSON, LYNN ELLEN (ANP)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:ELLEN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MS
Other - First Name:LYNN
Other - Middle Name:ELLEN
Other - Last Name:RETTIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:7404 W DARROW ST
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2643
Mailing Address - Country:US
Mailing Address - Phone:602-303-5376
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 13492
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78711-3492
Practice Address - Country:US
Practice Address - Phone:415-644-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001704363LA2200X
AZAP5555207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200514540Medicaid
IN000000562731OtherBLUE CROSS
INQ40166Medicare UPIN
IN200514540Medicaid
IN940670A9Medicare PIN