Provider Demographics
NPI:1740653807
Name:HENRY, KATHLEEN CHRISTINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:CHRISTINE
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 FORTUYN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND COULEE
Mailing Address - State:WA
Mailing Address - Zip Code:99133-8718
Mailing Address - Country:US
Mailing Address - Phone:509-633-1911
Mailing Address - Fax:509-633-1933
Practice Address - Street 1:411 FORTUYN RD
Practice Address - Street 2:
Practice Address - City:GRAND COULEE
Practice Address - State:WA
Practice Address - Zip Code:99133-8718
Practice Address - Country:US
Practice Address - Phone:509-633-1911
Practice Address - Fax:509-633-1933
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61036303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2155854Medicaid
WA0423364OtherLNI