Healthcare Provider Details

I. General information

NPI: 1891505616
Provider Name (Legal Business Name): HEATHER HENDERSON RN BSN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER GENTRY

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 W CARROLL AVE
CHICAGO IL
60612-2501
US

IV. Provider business mailing address

839 SHERWOOD PL
CHARLESTON IL
61920-1724
US

V. Phone/Fax

Practice location:
  • Phone: 217-508-9082
  • Fax:
Mailing address:
  • Phone: 217-508-9082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-317510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: