Provider Demographics
NPI:1093845570
Name:HENSON, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HENSON
Suffix:
Gender:F
Credentials:PA
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 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-243-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1010 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:POWDERLY
Practice Address - State:KY
Practice Address - Zip Code:42367-5463
Practice Address - Country:US
Practice Address - Phone:270-377-1600
Practice Address - Fax:270-338-0229
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA1023OtherPHYSICIAN ASSISTANCE LICENSE
KY7100022430Medicaid
KYTC002OtherLICENSE
K117662Medicare PIN
KY0652418Medicare PIN