Healthcare Provider Details

I. General information

NPI: 1497062590
Provider Name (Legal Business Name): AMANDA FAYE HENDERSON RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E 3RD ST
CHATTANOOGA TN
37403-2102
US

IV. Provider business mailing address

1300 SIDE CREEK WAY #207
CHATTANOOGA TN
37421-7911
US

V. Phone/Fax

Practice location:
  • Phone: 423-209-8050
  • Fax: 423-209-8051
Mailing address:
  • Phone: 270-282-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN0000177425
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: