Basic Information
| Provider Information | |||||||||
| NPI: | 1942710512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | KAYLEIGH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORGAN | ||||||||
| OtherFirstName: | KAYLEIGH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 S CREASY LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479054972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655024000 | ||||||||
| FaxNumber: | 7655024709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2017 | ||||||||
| LastUpdateDate: | 03/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71007570A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 28203292A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 300008725 | 05 | IN | MEDICAID | M47140310 | 01 | IN | MEDICARE PTAN | OTHER |