Provider Demographics
NPI:1205060415
Name:HENSON, KELLEY MARIE (NP)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:MARIE
Last Name:HENSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W D. L. INGRAM AVENUE
Mailing Address - Street 2:BLDG. 1408
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:757-902-7154
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE
Practice Address - Street 2:BLDG. 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:757-225-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN13239363LP0200X
VA0024169514363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508825902OtherJAMES BATSON NPI
TN1512646Medicaid
TN1538173471OtherCOOKEVILLE PEDIATRIC ASSOCIATES
TN1517710Medicaid
TN3897667Medicaid