Healthcare Provider Details

I. General information

NPI: 1366592859
Provider Name (Legal Business Name): KIMBERLY J HENDERSON M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 STAFFORD ST UNIT 6
MONROE NC
28110-3349
US

IV. Provider business mailing address

80 WARREN ST #32
NEW YORK NY
10007-1013
US

V. Phone/Fax

Practice location:
  • Phone: 980-290-5515
  • Fax:
Mailing address:
  • Phone: 917-471-0923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD15533
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301110971
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number60922767
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01077015A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number11085788-1205
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD043819
License Number StateDC
# 7
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD20776
License Number StateME
# 8
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD466064
License Number StatePA
# 9
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA09842100
License Number StateNJ
# 10
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number54929
License Number StateCT
# 11
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO080667
License Number StateMD
# 12
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number232889
License Number StateNY
# 13
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2020-00646
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: