Healthcare Provider Details

I. General information

NPI: 1023808094
Provider Name (Legal Business Name): MARY GRACE ELIZABETH HENDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 N DRUID HILLS RD NE
ATLANTA GA
30329-3117
US

IV. Provider business mailing address

3546 SANDY WOODS LN
STONE MOUNTAIN GA
30083-4054
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-7574
  • Fax:
Mailing address:
  • Phone: 770-625-0810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN308389
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: