Healthcare Provider Details

I. General information

NPI: 1114314424
Provider Name (Legal Business Name): COURTNEY HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 1ST CAPITOL DR
SAINT CHARLES MO
63301-2844
US

IV. Provider business mailing address

13515 BARRETT PARKWAY DR
BALLWIN MO
63021-5870
US

V. Phone/Fax

Practice location:
  • Phone: 314-775-2816
  • Fax:
Mailing address:
  • Phone: 314-775-2816
  • Fax: 314-775-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2015010654
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: