Healthcare Provider Details

I. General information

NPI: 1801256813
Provider Name (Legal Business Name): LISA L HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 E COOK ST
SPRINGFIELD IL
62703-1944
US

IV. Provider business mailing address

2239 E COOK ST
SPRINGFIELD IL
62703-1944
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-2300
  • Fax: 217-788-2342
Mailing address:
  • Phone: 217-788-2300
  • Fax: 217-788-2342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014399
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number041206559
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: