Healthcare Provider Details

I. General information

NPI: 1295748408
Provider Name (Legal Business Name): KENNETH ROY HENRY P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 CENTRAL PIKE
HERMITAGE TN
37076-3499
US

IV. Provider business mailing address

115 NEW HALLTOWN RD
HARTSVILLE TN
37074-1929
US

V. Phone/Fax

Practice location:
  • Phone: 615-883-2331
  • Fax:
Mailing address:
  • Phone: 615-374-0006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number749
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: