Provider Demographics
NPI:1790646594
Name:HENDERSON, AMMON TAYLOR
Entity type:Individual
Prefix:
First Name:AMMON
Middle Name:TAYLOR
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 ROBINS ST APT 6
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6575
Mailing Address - Country:US
Mailing Address - Phone:501-410-2610
Mailing Address - Fax:
Practice Address - Street 1:1111 W 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-1886
Practice Address - Country:US
Practice Address - Phone:918-582-1972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-20
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program