Basic Information
| Provider Information | |||||||||
| NPI: | 1851521215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAGNE HENDERSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, NP-C FNP ACHPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAGNE-HENDERSON | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD, NP-C FNP ACHPN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6400 SHAFER CT STE 700 | ||||||||
| Address2: | |||||||||
| City: | ROSEMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600184989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3463761702 | ||||||||
| FaxNumber: | 2245322780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1579 STRAITS TPKE STE 1E | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067621835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034901000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2009 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4925 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.