Provider Demographics
NPI:1538531405
Name:HENDERSON, NICOLE M (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 SE 108TH ST
Mailing Address - Street 2:
Mailing Address - City:RUNNELLS
Mailing Address - State:IA
Mailing Address - Zip Code:50237-1286
Mailing Address - Country:US
Mailing Address - Phone:515-306-8009
Mailing Address - Fax:
Practice Address - Street 1:606 N 7TH ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-9577
Practice Address - Country:US
Practice Address - Phone:641-842-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist