Healthcare Provider Details

I. General information

NPI: 1467832485
Provider Name (Legal Business Name): MARY ELLEN HENDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 DAVIS RD
WEST FALLS NY
14170-9781
US

IV. Provider business mailing address

6640 GARTMAN RD
ORCHARD PARK NY
14127-3722
US

V. Phone/Fax

Practice location:
  • Phone: 716-655-8776
  • Fax: 716-655-7877
Mailing address:
  • Phone: 716-667-6818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number362713 -1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: