Provider Demographics
NPI:1164979068
Name:HENDERSON, MARIAH (RN)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W SIEBENTHALER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-2243
Mailing Address - Country:US
Mailing Address - Phone:937-367-4375
Mailing Address - Fax:
Practice Address - Street 1:325 W SIEBENTHALER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-2243
Practice Address - Country:US
Practice Address - Phone:937-367-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.155860-M-IV164W00000X
OHRN525862163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse