Basic Information
Provider Information | |||||||||
NPI: | 1033558101 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDERSON | ||||||||
FirstName: | TESSA | ||||||||
MiddleName: | SUZANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MEUNIER, HOULE | ||||||||
OtherFirstName: | TESSA | ||||||||
OtherMiddleName: | SUZANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10700 E. GEDDES AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801123861 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037619190 | ||||||||
FaxNumber: | 7208744462 | ||||||||
Practice Location | |||||||||
Address1: | 10700 E GEDDES AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801123861 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037619190 | ||||||||
FaxNumber: | 7208744462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2013 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | APN.0990650-NP | CO | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LF0000X | APN.0990650-NP | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 384572YQPG | 01 | CO | MEDICARE | OTHER | 384572YQN9 | 01 | CO | MEDICARE | OTHER | 384572YQ3L | 01 | CO | MEDICARE | OTHER |