Provider Demographics
NPI:1609079839
Name:HENDERSON, KYWINA MARIE (FNP, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KYWINA
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:FNP, PMHNP-BC
Other - Prefix:MRS
Other - First Name:KYWINA
Other - Middle Name:MARIE
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP, PMHNP
Mailing Address - Street 1:1609 VERMONT PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1461
Mailing Address - Country:US
Mailing Address - Phone:909-788-4638
Mailing Address - Fax:
Practice Address - Street 1:13425 VENTURA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-3974
Practice Address - Country:US
Practice Address - Phone:818-305-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17177363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily