Healthcare Provider Details

I. General information

NPI: 1336223643
Provider Name (Legal Business Name): LINDA HENDERSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 NORTH DICKINSON
RUSK TX
75785-0318
US

IV. Provider business mailing address

1445 E MAIN ST
REKLAW TX
75784-2213
US

V. Phone/Fax

Practice location:
  • Phone: 903-683-3421
  • Fax:
Mailing address:
  • Phone: 903-683-3421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number240968
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: