Basic Information
| Provider Information | |||||||||
| NPI: | 1528591427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9816 MAYLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042828510 | ||||||||
| FaxNumber: | 8042855750 | ||||||||
| Practice Location | |||||||||
| Address1: | 5333 MCAULEY DR | ||||||||
| Address2: | SUITE 4001 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 0102206667 | VA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.