Healthcare Provider Details

I. General information

NPI: 1316452253
Provider Name (Legal Business Name): BRANDY DAVINA HENDERSON RN,FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 09/15/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 NORTHCUTT PL
DAYTON OH
45414-3840
US

IV. Provider business mailing address

9775 COLERAIN AVE
CINCINNATI OH
45251-1442
US

V. Phone/Fax

Practice location:
  • Phone: 937-496-2020
  • Fax: 937-496-2016
Mailing address:
  • Phone: 513-853-9700
  • Fax: 513-852-8971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRP277614
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.026361
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP.026361
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: