Basic Information
| Provider Information | |||||||||
| NPI: | 1043201304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20208 STATE HIGHWAY 155 S | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757625600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038256222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 618206 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-028 | 01 | TX | TRICARE LINDALE | OTHER | 834N61 | 01 | TX | BCBS | OTHER | 75-2616977-001 | 01 | TX | TRICARE- CANTON | OTHER | 142475605 | 05 | TX | MEDICAID | TIN PLUS 002 | 01 | TX | TRICARE LAKE PALESTINE LOCATION | OTHER | P00911377 | 01 | TX | MEDICARE RAILROAD | OTHER |