Basic Information
| Provider Information | |||||||||
| NPI: | 1972260644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | STEVENS | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1761 BEACON HILL RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596184930 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405367001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592571000 | ||||||||
| FaxNumber: | 8592573347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2021 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3014467 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3014467 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.