Provider Demographics
NPI:1871047399
Name:HENDERSON, LORI (NP-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 TEBEAU ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4728
Mailing Address - Country:US
Mailing Address - Phone:912-809-6052
Mailing Address - Fax:912-809-6070
Practice Address - Street 1:624 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4728
Practice Address - Country:US
Practice Address - Phone:912-809-6052
Practice Address - Fax:912-809-6070
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133742363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily