=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912470824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULA HENDERSON FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2019
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1906 GLENN BLVD SW STE 100A
-----------------------------------------------------
City | FORT PAYNE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35968-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-638-4411
-----------------------------------------------------
Fax | 256-638-9275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1906 GLENN BLVD SW STE 100A
-----------------------------------------------------
City | FORT PAYNE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-638-4411
-----------------------------------------------------
Fax | 256-638-9275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2017033470
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------