Provider Demographics
NPI:1962534107
Name:HENDERSON, MARTHA KAYE LLOYD
Entity type:Individual
Prefix:MRS
First Name:MARTHA KAYE
Middle Name:LLOYD
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 1:2347 SIMONTON RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8246
Mailing Address - Country:US
Mailing Address - Phone:704-873-4719
Mailing Address - Fax:704-872-1810
Practice Address - Street 1:2347 SIMONTON RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8246
Practice Address - Country:US
Practice Address - Phone:704-873-4719
Practice Address - Fax:704-872-1810
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ58469Medicare UPIN