Basic Information
| Provider Information | |||||||||
| NPI: | 1518496504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSEN | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAUGEN | ||||||||
| OtherFirstName: | KELSEY | ||||||||
| OtherMiddleName: | BLAIR | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2360 E PERSHING BLVD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794434301 | ||||||||
| FaxNumber: | 4795876105 | ||||||||
| Practice Location | |||||||||
| Address1: | 2360 E PERSHING BLVD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077787550 | ||||||||
| FaxNumber: | 3077787594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2931 | OK | N | Eye and Vision Services Providers | Optometrist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | 3438 | CO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.