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General NPI Number Information
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NPI Number | 1487256129
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Entity Type | Individual
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Provider Name | NICHOLE YVONNE HENDERSON
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Gender | Female
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Dates
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Enumeration Date | 11/09/2020
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Last Update Date | 11/09/2020
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Provider Practice Location Address
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Address Line | 13059 FAIR LAKES PKWY
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City | FAIRFAX
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State | VA
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Zip | 22033
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Country | US
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Telephone | 703-631-4007
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Fax | 703-631-4758
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Provider Business Mailing Address
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Address Line | 13108 PELFREY LN
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City | FAIRFAX
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State | VA
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Zip | 22033-3028
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Country | US
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Telephone | 703-622-8834
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Fax | 703-622-8834
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 0202012188
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License Number State | VA
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