Provider Demographics
NPI:1114991361
Name:HENDERSON, KIMBERLY E (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2902
Mailing Address - Country:US
Mailing Address - Phone:218-829-3235
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:507-884-4856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN996363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN313637000Medicaid
P03341Medicare UPIN
MN500028651Medicare ID - Type UnspecifiedRAILROAD
MN500002239Medicare ID - Type Unspecified