Provider Demographics
NPI:1225145865
Name:HENDERSON, KELLIE LAWRENCE (PA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LAWRENCE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MICHELE
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1508 TOMBRAS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2720
Mailing Address - Country:US
Mailing Address - Phone:423-867-4969
Mailing Address - Fax:423-867-4971
Practice Address - Street 1:1508 TOMBRAS AVE
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2720
Practice Address - Country:US
Practice Address - Phone:423-867-4969
Practice Address - Fax:423-867-4971
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001098363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4219886OtherBCBS- TENNESSEE
TNQ007546Medicaid
TN4219886OtherBCBS- TENNESSEE