Healthcare Provider Details

I. General information

NPI: 1124627930
Provider Name (Legal Business Name): BETH HARRIS HENDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4784 W US HIGHWAY 90
LAKE CITY FL
32055-3101
US

IV. Provider business mailing address

23343 NW COUNTY ROAD 236
HIGH SPRINGS FL
32643-9669
US

V. Phone/Fax

Practice location:
  • Phone: 386-269-9260
  • Fax: 386-406-6714
Mailing address:
  • Phone: 386-454-0698
  • Fax: 386-454-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11008627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: