MEDICARE: MRS. HEATHER K HENDERSON NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F401141	NY
2	163W00000X	Registered Nurse	552060	NY
3	363L00000X	Nurse Practitioner	F401141-1	NY

General Provider Information

NPI Number	:	1255589909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEATHER K HENDERSON NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	5016 W GENESEE ST
Second Line	:
City	:	CAMILLUS
State	:	NY
Zip	:	13031-2356
Country	:	US
Telephone Number	:	315-496-1020
Fax Number	:	315-226-7236

Provider Business Practice Location Address
First Line	:	5016 W GENESEE ST
Second Line	:
City	:	CAMILLUS
State	:	NY
Zip	:	13031-2356
Country	:	US
Telephone Number	:	315-496-1020
Fax Number	:	315-226-7236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2008
Last Update Date	:	06/03/2026

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