Healthcare Provider Details

I. General information

NPI: 1245694140
Provider Name (Legal Business Name): VESTA LEE HENDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 VETERANS WAY
VIERA FL
32940-8007
US

IV. Provider business mailing address

346 BEACH PARK LN
CAPE CANAVERAL FL
32920-5031
US

V. Phone/Fax

Practice location:
  • Phone: 321-637-3788
  • Fax:
Mailing address:
  • Phone: 207-253-9385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN2991522
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: