Healthcare Provider Details

I. General information

NPI: 1568380251
Provider Name (Legal Business Name): BRIANNE HENDERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 LEWIS ST
NORTH POLE AK
99705-7699
US

IV. Provider business mailing address

4731 SOAPBERRY LOOP UNIT 1
FORT WAINWRIGHT AK
99703-1401
US

V. Phone/Fax

Practice location:
  • Phone: 907-488-4978
  • Fax:
Mailing address:
  • Phone: 808-286-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number169142
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: