Provider Demographics
NPI:1699149443
Name:HENDERSON, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 WASHINGTON BLVD
Mailing Address - Street 2:APT 1706
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1719
Mailing Address - Country:US
Mailing Address - Phone:313-646-5591
Mailing Address - Fax:
Practice Address - Street 1:1410 WASHINGTON BLVD
Practice Address - Street 2:APT 1706
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1719
Practice Address - Country:US
Practice Address - Phone:313-646-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH536067081873Medicaid