Healthcare Provider Details

I. General information

NPI: 1962167676
Provider Name (Legal Business Name): MRS. LESLIE GAYLE HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 LOWER RIDGE RD
CONWAY AR
72032-8518
US

IV. Provider business mailing address

PO BOX 1589
BENTON AR
72018-1589
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-3344
  • Fax:
Mailing address:
  • Phone: 501-315-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: