MEDICARE: AMANDA SUSAN HENDERSON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	39960	TN

General Provider Information

NPI Number	:	1053122135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA SUSAN HENDERSON RN

Provider Business Mailing Address
First Line	:	461 21ST AVE S
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37240-1104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 DOWELL SPRINGS BLVD STE 330
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37909-2445
Country	:	US
Telephone Number	:	608-225-3958
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2025
Last Update Date	:	10/07/2025

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