Healthcare Provider Details

I. General information

NPI: 1164802484
Provider Name (Legal Business Name): ASHLEY NICOLE HENDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY NICOLE LANDICHO M.D.

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICAL CENTER BOULEVARD SUITE #205
CHESTER PA
19013
US

IV. Provider business mailing address

30 MEDICAL CENTER BOULEVARD SUITE #205
CHESTER PA
19013
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-7410
  • Fax:
Mailing address:
  • Phone: 610-619-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD463851
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: