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General NPI Number Information
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NPI Number | 1336373240
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Entity Type | Organization
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Legal Business Name | HENSON MEDICAL CLINIC, INC.
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Dates
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Enumeration Date | 05/06/2009
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Last Update Date | 05/06/2009
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Provider Practice Location Address
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Address Line | 200 W RAILROAD ST 104
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City | LONG BEACH
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State | MS
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Zip | 39560-4517
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Country | US
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Telephone | 228-864-0622
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Fax | 228-864-7958
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Provider Business Mailing Address
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Address Line | PO BOX 609
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City | LONG BEACH
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State | MS
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Zip | 39560-0609
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Country | US
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Telephone | 228-864-0622
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Fax | 228-864-7958
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. WANDA F. HENSON
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Credential | FNP-BC
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Telephone | 228-864-0622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R862256
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R518328
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License Number State | MS
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