Healthcare Provider Details

I. General information

NPI: 1336373240
Provider Name (Legal Business Name): HENSON MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W RAILROAD ST 104
LONG BEACH MS
39560-4517
US

IV. Provider business mailing address

PO BOX 609
LONG BEACH MS
39560-0609
US

V. Phone/Fax

Practice location:
  • Phone: 228-864-0622
  • Fax: 228-864-7958
Mailing address:
  • Phone: 228-864-0622
  • Fax: 228-864-7958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR862256
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR518328
License Number StateMS

VIII. Authorized Official

Name: MRS. WANDA F. HENSON
Title or Position: EXECUTIVE DIRECTOR
Credential: FNP-BC
Phone: 228-864-0622