Provider Demographics
NPI:1720252489
Name:HENDERSON, KELLI (RN)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
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 1:1705 REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1536
Mailing Address - Country:US
Mailing Address - Phone:618-926-2263
Mailing Address - Fax:
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0800XNursing Service ProvidersRegistered NurseOrthopedic