Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | GAA-NP000193 | GA |
NPI | 1003580986 |
---|---|
Provider Name | Mr. Terrance B Henderson |
First Address | Duluth, GA 30096-5904 |
Second Address | Duluth, GA 30096-5904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2021 |
Last Update Date | 04/08/2021 |