Provider Demographics
NPI:1861019283
Name:HENDERSON, SHELBY (OD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4051 NICHOLASVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-4433
Mailing Address - Country:US
Mailing Address - Phone:859-272-1422
Mailing Address - Fax:859-273-4582
Practice Address - Street 1:4051 NICHOLASVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-4433
Practice Address - Country:US
Practice Address - Phone:859-272-1422
Practice Address - Fax:859-273-4582
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2177DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist