Basic Information
| Provider Information | |||||||||
| NPI: | 1164802484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANDICHO | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | SUITE #205 | ||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197410 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | SUITE #205 | ||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197410 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD463851 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.