Healthcare Provider Details

I. General information

NPI: 1194652859
Provider Name (Legal Business Name): SANDRA HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17130 SEQUOIA ST STE 104
HESPERIA CA
92345-1827
US

IV. Provider business mailing address

14288 NANTUCKET ST
HESPERIA CA
92344-8285
US

V. Phone/Fax

Practice location:
  • Phone: 844-982-6374
  • Fax: 562-361-9516
Mailing address:
  • Phone: 844-982-6374
  • Fax: 562-361-9516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: