Provider Demographics
NPI:1740369867
Name:HENDERSON, KENYA (PAC)
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KENYA
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:16350 VENTURA BLVD
Mailing Address - Street 2:STE D323
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-5300
Mailing Address - Country:US
Mailing Address - Phone:818-762-1167
Mailing Address - Fax:818-762-9992
Practice Address - Street 1:12311 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2509
Practice Address - Country:US
Practice Address - Phone:818-762-1167
Practice Address - Fax:818-762-9992
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02517Medicare UPIN