Provider Demographics
NPI:1548049265
Name:KYWINA M HENDERSON PROFESSIONAL ADVANCED PRACTICE NURSING CORPORAT
Entity type:Organization
Organization Name:KYWINA M HENDERSON PROFESSIONAL ADVANCED PRACTICE NURSING CORPORAT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:KYWINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PMHNP
Authorized Official - Phone:909-788-4638
Mailing Address - Street 1:1112 DANIELS ST STE 10
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3063
Mailing Address - Country:US
Mailing Address - Phone:425-728-2721
Mailing Address - Fax:425-490-6547
Practice Address - Street 1:1112 DANIELS ST STE 10
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3063
Practice Address - Country:US
Practice Address - Phone:818-305-6061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-22
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty