Provider Demographics
NPI:1780913129
Name:HENDERSON, KATHI LEE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KATHI
Middle Name:LEE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-1407
Mailing Address - Country:US
Mailing Address - Phone:580-225-4466
Mailing Address - Fax:580-225-2417
Practice Address - Street 1:1513 N RANDALL AVE
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644
Practice Address - Country:US
Practice Address - Phone:580-225-4466
Practice Address - Fax:580-225-2417
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20091470364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics