Healthcare Provider Details

I. General information

NPI: 1255450813
Provider Name (Legal Business Name): CYNTHIA COTHREN HENDERSON ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 02/18/2024
Certification Date: 02/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6029 WALNUT GROVE RD STE 210
MEMPHIS TN
38120-2112
US

IV. Provider business mailing address

778 LIBERTY RD
FLOWOOD MS
39232-9300
US

V. Phone/Fax

Practice location:
  • Phone: 601-914-9620
  • Fax: 601-914-9620
Mailing address:
  • Phone: 601-914-9620
  • Fax: 601-914-9620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPN0000006741
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: