Healthcare Provider Details

I. General information

NPI: 1013744507
Provider Name (Legal Business Name): JUSTIN SCOT HENDERSON RN, CWCN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

414 INTERSTATE BLVD
HARWOOD ND
58042-4001
US

V. Phone/Fax

Practice location:
  • Phone: 701-451-4688
  • Fax:
Mailing address:
  • Phone: 701-793-2064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberR33505
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: