Healthcare Provider Details

I. General information

NPI: 1104736123
Provider Name (Legal Business Name): SHAMICA HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5439 S TACOMA WAY
TACOMA WA
98409-4312
US

IV. Provider business mailing address

1723 S 47TH ST
TACOMA WA
98408-1508
US

V. Phone/Fax

Practice location:
  • Phone: 206-551-7462
  • Fax:
Mailing address:
  • Phone: 206-551-7462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: