Healthcare Provider Details

I. General information

NPI: 1972647519
Provider Name (Legal Business Name): KENYA HENDERSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MCINGVALE RD
HERNANDO MS
38632-8658
US

IV. Provider business mailing address

2600 MCINGVALE RD
HERNANDO MS
38632-8658
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-7099
  • Fax: 662-449-3021
Mailing address:
  • Phone: 662-429-7099
  • Fax: 662-449-3021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2618
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number741
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: