Provider Demographics
NPI:1639281843
Name:HENDERSON, KIMBERLY CONNER (CRNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CONNER
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:OAKMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15139-2072
Mailing Address - Country:US
Mailing Address - Phone:412-423-1048
Mailing Address - Fax:
Practice Address - Street 1:333 ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:OAKMONT
Practice Address - State:PA
Practice Address - Zip Code:15139-2072
Practice Address - Country:US
Practice Address - Phone:412-423-1048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP005788B363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA158728Medicare PIN