Provider Demographics
NPI:1508559964
Name:HENSON, KIMBERLY NICOLE STA ANA (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY NICOLE
Middle Name:STA ANA
Last Name:HENSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-2733
Mailing Address - Country:US
Mailing Address - Phone:573-768-5958
Mailing Address - Fax:
Practice Address - Street 1:1609 N PRINCE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4850
Practice Address - Country:US
Practice Address - Phone:575-935-0360
Practice Address - Fax:575-935-0361
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist