Provider Demographics
NPI:1215027206
Name:OBANNON HENDERSON, KOLLEEN (NP)
Entity Type:Individual
Prefix:MRS
First Name:KOLLEEN
Middle Name:
Last Name:OBANNON 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 1:3469 N VERDUGO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208
Mailing Address - Country:US
Mailing Address - Phone:818-249-6636
Mailing Address - Fax:818-249-5074
Practice Address - Street 1:3469 N VERDUGO RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208
Practice Address - Country:US
Practice Address - Phone:818-249-6636
Practice Address - Fax:818-249-5074
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA350799207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology