Healthcare Provider Details

I. General information

NPI: 1194688093
Provider Name (Legal Business Name): BRIANA HENDERSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11868 ACADEMIC OVAL HAZEL HALL SUITE 1034
PRINCESS ANNE MD
21853-1295
US

IV. Provider business mailing address

11868 ACADEMIC OVAL HAZEL HALL SUITE 1034
PRINCESS ANNE MD
21853-1295
US

V. Phone/Fax

Practice location:
  • Phone: 410-621-3032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: