Provider Demographics
NPI:1114992930
Name:HENDERSON, KATINA LENEIL (RN)
Entity Type:Individual
Prefix:MR
First Name:KATINA
Middle Name:LENEIL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:FT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4603
Mailing Address - Country:US
Mailing Address - Phone:719-526-7649
Mailing Address - Fax:719-526-7019
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-524-2047
Practice Address - Fax:719-524-3526
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO116976163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice