Basic Information
| Provider Information | |||||||||
| NPI: | 1063081289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | SUSANNE | ||||||||
| MiddleName: | NOEL | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536276576 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536276576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2021 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP61159008 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | AP61159008 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 217925 | 05 | WA | MEDICAID |