Basic Information
| Provider Information | |||||||||
| NPI: | 1003580986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | TERRANCE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2789 SATELLITE BLVD UNIT 2119 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300965904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173732184 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3180 N POINT PKWY STE 302 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048005181 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | GAA-NP000193 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.