Provider Demographics
NPI:1720571441
Name:HENDERSON, LORA JELISE
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:JELISE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 RICELAND DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5383
Mailing Address - Country:US
Mailing Address - Phone:919-810-1932
Mailing Address - Fax:
Practice Address - Street 1:801 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1424
Practice Address - Country:US
Practice Address - Phone:919-810-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program