Provider Demographics
NPI:1952425514
Name:HENDERSON, KELLEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 UNIVERSITY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514
Mailing Address - Country:US
Mailing Address - Phone:850-291-2501
Mailing Address - Fax:
Practice Address - Street 1:11000 UNIVERSITY PARKWAY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514
Practice Address - Country:US
Practice Address - Phone:817-257-5573
Practice Address - Fax:817-257-7702
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT38042255A2300X
FLAL10312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer