Provider Demographics
NPI:1730805979
Name:HENRY, KRISTAL (APRN)
Entity type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18417 E 1200 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-7951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-554-6827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
IL209026060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care