Provider Demographics
NPI:1548261670
Name:HENDERSON, LAUREL ANN (FNP)
Entity type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:LAUREL
Other - Middle Name:ANN
Other - Last Name:HAYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1429 GILL ST
Mailing Address - Street 2:APT 4410
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2900
Mailing Address - Country:US
Mailing Address - Phone:315-222-3100
Mailing Address - Fax:
Practice Address - Street 1:35 EMPSALL PLAZA
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-6400
Practice Address - Fax:315-782-1330
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF#334502363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner