Healthcare Provider Details

I. General information

NPI: 1902268527
Provider Name (Legal Business Name): MARNI MARIE HENDERSON B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6393 S RED SHINE WAY
BOISE ID
83709-6509
US

IV. Provider business mailing address

6393 S RED SHINE WAY
BOISE ID
83709-6509
US

V. Phone/Fax

Practice location:
  • Phone: 208-440-1230
  • Fax:
Mailing address:
  • Phone: 208-440-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberB.S. COMMUNITY HEALT
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number174H00000X
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: