Healthcare Provider Details

I. General information

NPI: 1083162762
Provider Name (Legal Business Name): MICHELLE HENDERSON RNFA, CNOR, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE ADAMSON HENDERSON

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 COUNTY ROAD 459
HEFLIN AL
36264-4090
US

IV. Provider business mailing address

1175 COUNTY ROAD 459
HEFLIN AL
36264-4090
US

V. Phone/Fax

Practice location:
  • Phone: 770-846-9526
  • Fax:
Mailing address:
  • Phone: 770-846-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN217566
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: