Healthcare Provider Details

I. General information

NPI: 1033106653
Provider Name (Legal Business Name): AMY DENISE HENSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N MAIN ST
LONDON KY
40741-1217
US

IV. Provider business mailing address

503 N MAIN ST
LONDON KY
40741-1217
US

V. Phone/Fax

Practice location:
  • Phone: 606-877-1877
  • Fax: 606-878-9543
Mailing address:
  • Phone: 606-877-1877
  • Fax: 606-878-9543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1574DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: