Healthcare Provider Details

I. General information

NPI: 1255589909
Provider Name (Legal Business Name): HEATHER K HENDERSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2008
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5016 W GENESEE ST
CAMILLUS NY
13031-2356
US

IV. Provider business mailing address

5016 W GENESEE ST
CAMILLUS NY
13031-2356
US

V. Phone/Fax

Practice location:
  • Phone: 315-496-1020
  • Fax: 315-226-7236
Mailing address:
  • Phone: 315-496-1020
  • Fax: 315-226-7236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401141
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number552060
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF401141-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: