Healthcare Provider Details

I. General information

NPI: 1417924358
Provider Name (Legal Business Name): SHERRI LEANN HENDERSON PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHERRI LEANN GREEN

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N WICKHAM RD STE 108
MELBOURNE FL
32935-8663
US

IV. Provider business mailing address

240 N WICKHAM RD STE 108
MELBOURNE FL
32935-8663
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-1777
  • Fax: 321-841-1788
Mailing address:
  • Phone: 321-541-1777
  • Fax: 321-541-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9105795
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105795
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: