Provider Demographics
NPI:1184850984
Name:HENDERSON, KELLIE N (PHARMD, BCNSP)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:N
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHARMD, BCNSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:ET-B069
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-6651
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:ET-B069
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS280151835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support