Healthcare Provider Details

I. General information

NPI: 1821254145
Provider Name (Legal Business Name): NANINE S HENDERSON DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 DUPONT CIR SUITE 200
LOUISVILLE KY
40207-4812
US

IV. Provider business mailing address

4010 DUPONT CIR SUITE 200
LOUISVILLE KY
40207-4812
US

V. Phone/Fax

Practice location:
  • Phone: 502-893-5422
  • Fax: 502-896-4962
Mailing address:
  • Phone: 502-893-5422
  • Fax: 502-896-4962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: NANINE SCOT HENDERSON
Title or Position: PHYSICIAN
Credential: DO
Phone: 502-893-5422