Provider Demographics
NPI:1013744507
Name:HENDERSON, JUSTIN SCOT (RN, CWCN)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SCOT
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:RN, CWCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 INTERSTATE BLVD
Mailing Address - Street 2:
Mailing Address - City:HARWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58042-4001
Mailing Address - Country:US
Mailing Address - Phone:701-793-2064
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-451-4688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR33505163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care