Provider Demographics
NPI:1285260570
Name:HENDERSON, KATHLEEN ANN (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 N PRINCE EDWARD IS
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-6702
Mailing Address - Country:US
Mailing Address - Phone:913-461-4747
Mailing Address - Fax:913-632-2898
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-632-2831
Practice Address - Fax:913-632-2898
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77431-122364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health