Provider Demographics
NPI:1457657793
Name:HENRY, KELLY DIANE (RN, PMHNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:HENRY
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 GOODPASTURE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2109
Mailing Address - Country:US
Mailing Address - Phone:541-636-9846
Mailing Address - Fax:541-636-9847
Practice Address - Street 1:331 GOODPASTURE ISLAND RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2109
Practice Address - Country:US
Practice Address - Phone:541-636-9846
Practice Address - Fax:541-636-9847
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150087NP363LP0808X, 363LP0808X
OR200942615RN163W00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500644984Medicaid