Provider Demographics
NPI:1790070787
Name:HENDERSON, KIMBERLY JILL (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JILL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 ROUTE 55
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5108
Mailing Address - Country:US
Mailing Address - Phone:845-475-9661
Mailing Address - Fax:845-475-9938
Practice Address - Street 1:334 PLAZA RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-2975
Practice Address - Country:US
Practice Address - Phone:845-338-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278817207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04091058Medicaid
NY04091058Medicaid