Healthcare Provider Details

I. General information

NPI: 1912972779
Provider Name (Legal Business Name): KATHRYN ALYCE HENICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SANTA MONICA BLVD SUITE 400E
SANTA MONICA CA
90404-2208
US

IV. Provider business mailing address

2021 SANTA MONICA BLVD. SUITE 400E
LOS ANGELES CA
90064-3205
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-5654
  • Fax: 310-453-6885
Mailing address:
  • Phone: 310-453-5654
  • Fax: 310-453-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberG78994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: