Provider Demographics
NPI:1962522854
Name:HENDERSON, SHIRLEY C (LPN)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 COUNTY ROAD 1101
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-9630
Mailing Address - Country:US
Mailing Address - Phone:662-728-0377
Mailing Address - Fax:
Practice Address - Street 1:249 COUNTY ROAD 1101
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-9630
Practice Address - Country:US
Practice Address - Phone:662-728-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP194832164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0077348Medicaid