Provider Demographics
NPI:1780321497
Name:HENRY, KENESHIA
Entity type:Individual
Prefix:
First Name:KENESHIA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11369
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90749-1369
Mailing Address - Country:US
Mailing Address - Phone:424-340-2347
Mailing Address - Fax:
Practice Address - Street 1:20700 AVALON BLVD STE 190
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3708
Practice Address - Country:US
Practice Address - Phone:424-340-2347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-14
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1396852085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound