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NPI Code Detail

MEDICARE: CHANELLE HENDERSON

MEDICARE: CHANELLE 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
1374J00000XDoula

General Provider Information

NPI Number : 1790619302
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHANELLE HENDERSON
Provider Business Mailing Address
First Line : 3614 KIPLING AVE
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55416-4818
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1121 JACKSON ST NE STE 100
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55413-3051
Country : US
Telephone Number : 612-353-6293
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2026
Last Update Date : 06/09/2026

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Directions to “ CHANELLE HENDERSON ” Practice Location

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