Provider Demographics
NPI:1962530113
Name:HENDERSON, BRIDGETTE L (NP)
Entity type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2122
Mailing Address - Country:US
Mailing Address - Phone:856-983-0411
Mailing Address - Fax:
Practice Address - Street 1:99 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2122
Practice Address - Country:US
Practice Address - Phone:856-983-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10905100363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8571007Medicaid
NJ046265PQPMedicare ID - Type Unspecified
NJP26925Medicare UPIN