MEDICARE: MRS. MONIQUE 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	171M00000X	Case Manager/Care Coordinator
2	174H00000X	Health Educator

General Provider Information

NPI Number	:	1639407851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MONIQUE HENDERSON

Provider Business Mailing Address
First Line	:	11137 TARA BLVD
Second Line	:	SUITE 230-154
City	:	HAMPTON
State	:	GA
Zip	:	30228-1672
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11137 TARA BLVD
Second Line	:	SUITE 230-154
City	:	HAMPTON
State	:	GA
Zip	:	30228-1672
Country	:	US
Telephone Number	:	678-325-7936
Fax Number	:

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

Provider Enumeration Date	:	11/29/2009
Last Update Date	:	11/29/2009

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