Provider Demographics
NPI:1174813281
Name:HENDERSON, LAUREN (DO)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S MAIN ST
Mailing Address - Street 2:APT 803
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2454
Mailing Address - Country:US
Mailing Address - Phone:601-214-0346
Mailing Address - Fax:
Practice Address - Street 1:10 S MAIN ST
Practice Address - Street 2:APT 803
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2454
Practice Address - Country:US
Practice Address - Phone:601-214-0346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-10
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN2664207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program