Provider Demographics
NPI:1912424243
Name:HENDERSON, LISA YVETTE (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:YVETTE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 TURKLE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67060-1754
Mailing Address - Country:US
Mailing Address - Phone:316-308-5768
Mailing Address - Fax:
Practice Address - Street 1:VA BLACK HILLS HEALTH CARE SYSTEM
Practice Address - Street 2:113 COMANCHE RD
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741
Practice Address - Country:US
Practice Address - Phone:605-745-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK118316363L00000X, 363LA2200X
KS53-77543-021363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology