Provider Demographics
NPI:1225406440
Name:SENESOURY, KHANKHAM KAITLYN (NP)
Entity Type:Individual
Prefix:
First Name:KHANKHAM
Middle Name:KAITLYN
Last Name:SENESOURY
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 1:1200 W WALNUT HILL LN
Mailing Address - Street 2:STE. 3950
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3029
Mailing Address - Country:US
Mailing Address - Phone:972-514-1672
Mailing Address - Fax:
Practice Address - Street 1:3101 DENTON HWY
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3706
Practice Address - Country:US
Practice Address - Phone:817-831-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily