Provider Demographics
NPI:1346619715
Name:HENSLEY, ALICIA DIANE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:DIANE
Last Name:HENSLEY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:D
Other - Last Name:COFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 E BOW ST
Practice Address - Street 2:
Practice Address - City:THORNTOWN
Practice Address - State:IN
Practice Address - Zip Code:46071-1164
Practice Address - Country:US
Practice Address - Phone:765-436-2400
Practice Address - Fax:765-436-7375
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28176948A163W00000X
IN71005725A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201331770Medicaid