Basic Information
| Provider Information | |||||||||
| NPI: | 1902403215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | FAYE | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 ONION HILL RD | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370581410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313051925 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1021 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370583302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312325329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2020 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 84371 | TN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.