Provider Demographics
NPI:1831880152
Name:HENDERSON, KRISJAN MIKKEL
Entity type:Individual
Prefix:
First Name:KRISJAN
Middle Name:MIKKEL
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-4762
Mailing Address - Country:US
Mailing Address - Phone:515-829-6540
Mailing Address - Fax:
Practice Address - Street 1:534 WALLACE RD
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50011-4008
Practice Address - Country:US
Practice Address - Phone:515-294-8718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer