Provider Demographics
NPI:1417531104
Name:HENSON, KEVIN (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HENSON
Suffix:
Gender:M
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2616
Mailing Address - Country:US
Mailing Address - Phone:610-733-1211
Mailing Address - Fax:
Practice Address - Street 1:3814 AUBURN BLVD STE 72
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-2123
Practice Address - Country:US
Practice Address - Phone:916-426-1902
Practice Address - Fax:916-647-0156
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017287363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty