MEDICARE: MYRA A HENDERSON D.O.

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	207VE0102X	Reproductive Endocrinology Physician	02554	KY
2	207V00000X	Obstetrics & Gynecology Physician	02554	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427151430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRA A HENDERSON D.O.

Provider Business Mailing Address
First Line	:	1115 WOODLAND DR
Second Line	:
City	:	ELIZABETHTOWN
State	:	KY
Zip	:	42701-2749
Country	:	US
Telephone Number	:	270-769-5963
Fax Number	:	270-769-9051

Provider Business Practice Location Address
First Line	:	1115 WOODLAND DR
Second Line	:
City	:	ELIZABETHTOWN
State	:	KY
Zip	:	42701-2749
Country	:	US
Telephone Number	:	270-769-5963
Fax Number	:	270-769-9051

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

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	03/02/2026

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