Provider Demographics
NPI:1194958355
Name:HENRY, KELLY LEE (RN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEE
Last Name:HENRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:LEE
Other - Last Name:CUSIC HENRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:105 HILLPINE RD
Mailing Address - Street 2:APT E-1
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2429
Mailing Address - Country:US
Mailing Address - Phone:803-740-5197
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR 200774163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse