MEDICARE: GERMAINE M HENDERSON

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	363LF0000X	Family Nurse Practitioner	209014447	IL

General Provider Information

NPI Number	:	1558714386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERMAINE M HENDERSON

Provider Business Mailing Address
First Line	:	21200 S LA GRANGE RD STE 189
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-2003
Country	:	US
Telephone Number	:	312-632-9776
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 E 47TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4507
Country	:	US
Telephone Number	:	312-663-9776
Fax Number	:

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

Provider Enumeration Date	:	07/17/2016
Last Update Date	:	08/16/2021

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