Provider Demographics
NPI:1083720726
Name:HENDERSON, KRISTI A (NP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16076
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-6076
Mailing Address - Country:US
Mailing Address - Phone:601-936-6001
Mailing Address - Fax:601-936-4389
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-936-6001
Practice Address - Fax:601-936-4389
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850357363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I500551OtherMEDICARE PTAN EFFECTIVE 7/2/08
MS00118929Medicaid
MS302I508840Medicare PIN
MSS52011Medicare UPIN