Healthcare Provider Details

I. General information

NPI: 1205060415
Provider Name (Legal Business Name): KELLEY MARIE HENSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 05/23/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W D. L. INGRAM AVENUE BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

224 W D. L. INGRAM AVENUE BLDG. 1408
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 757-225-6611
  • Fax:
Mailing address:
  • Phone: 757-902-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPN13239
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024169514
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: