=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568380251
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIANNE HENDERSON PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2026
-----------------------------------------------------
Last Update Date | 07/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 LEWIS ST
-----------------------------------------------------
City | NORTH POLE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99705-7699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-488-4978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4731 SOAPBERRY LOOP UNIT 1
-----------------------------------------------------
City | FORT WAINWRIGHT
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99703-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-286-1281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 169142
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------