MEDICARE: KENYATTA HENDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209029766	IL

General Provider Information

NPI Number	:	1407729163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYATTA HENDERSON

Provider Business Mailing Address
First Line	:	9950 S ARTESIAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1051
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9950 S ARTESIAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1051
Country	:	US
Telephone Number	:	888-523-8268
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2025
Last Update Date	:	10/24/2025

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