Provider Demographics
NPI:1750399911
Name:HENDERSON, MARJORIE L (MD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-494-6700
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:508 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3547
Practice Address - Country:US
Practice Address - Phone:509-574-6139
Practice Address - Fax:509-574-6138
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019316208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033422Medicaid
WAGAB38059Medicare Oscar/Certification
WA1033422Medicaid
G8800360Medicare PIN