Healthcare Provider Details

I. General information

NPI: 1851521215
Provider Name (Legal Business Name): REBECCA GAGNE HENDERSON PHD, NP-C FNP ACHPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA GAGNE-HENDERSON PHD, NP-C FNP ACHPN

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 STRAITS TPKE STE 1E
MIDDLEBURY CT
06762-1835
US

IV. Provider business mailing address

6400 SHAFER CT STE 700
ROSEMONT IL
60018-4989
US

V. Phone/Fax

Practice location:
  • Phone: 203-490-1000
  • Fax:
Mailing address:
  • Phone: 346-376-1702
  • Fax: 224-532-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4925
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: