Healthcare Provider Details

I. General information

NPI: 1912424243
Provider Name (Legal Business Name): LISA YVETTE HENDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E BROADWAY ST
CUSHING OK
74023-3432
US

IV. Provider business mailing address

601 E BROADWAY ST
CUSHING OK
74023-3432
US

V. Phone/Fax

Practice location:
  • Phone: 316-308-5768
  • Fax:
Mailing address:
  • Phone: 316-308-5768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number118316
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number118316
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number53-77543-021
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number53-77543-021
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: