Provider Demographics
NPI:1386240463
Name:HENDERSON, KYLIE (NP)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5062 N 500 E # N500E
Mailing Address - Street 2:
Mailing Address - City:WINDFALL
Mailing Address - State:IN
Mailing Address - Zip Code:46076-9323
Mailing Address - Country:US
Mailing Address - Phone:765-620-9432
Mailing Address - Fax:
Practice Address - Street 1:12900 N MERIDIAN ST STE 140
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5401
Practice Address - Country:US
Practice Address - Phone:765-388-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010612A363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health