Provider Demographics
NPI:1194982041
Name:HENSON, HOLLY JEANNE (ARNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEANNE
Last Name:HENSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:JEANNE
Other - Last Name:LEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2101 LITTLE MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-8752
Mailing Address - Country:US
Mailing Address - Phone:360-428-2622
Mailing Address - Fax:360-428-3941
Practice Address - Street 1:2101 LITTLE MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-8752
Practice Address - Country:US
Practice Address - Phone:360-428-2622
Practice Address - Fax:360-428-3941
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60020709363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9657297Medicaid