Provider Demographics
NPI:1588999270
Name:HENDERSON, TRACEY (ARNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-3041
Mailing Address - Fax:712-852-5692
Practice Address - Street 1:3201 1ST ST
Practice Address - Street 2:
Practice Address - City:EMMETSBURG
Practice Address - State:IA
Practice Address - Zip Code:50536-2516
Practice Address - Country:US
Practice Address - Phone:712-852-5555
Practice Address - Fax:712-852-5692
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
MNR192078-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No282N00000XHospitalsGeneral Acute Care Hospital