Provider Demographics
NPI:1083024491
Name:HENDERSON, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901
Mailing Address - Country:US
Mailing Address - Phone:203-653-4700
Mailing Address - Fax:
Practice Address - Street 1:707 SUMMER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1026
Practice Address - Country:US
Practice Address - Phone:203-653-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670204-1163W00000X
CT110682163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse