Provider Demographics
NPI:1316441769
Name:WILSON-HENJUM, KELSEY L (MD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:WILSON-HENJUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W 56TH ST APT 2208
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3577
Mailing Address - Country:US
Mailing Address - Phone:301-908-9443
Mailing Address - Fax:
Practice Address - Street 1:1 FORDHAM PLZ FL 5
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5871
Practice Address - Country:US
Practice Address - Phone:718-933-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY305020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program