Provider Demographics
NPI:1750738571
Name:HENSON, KAYLA ROSE
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ROSE
Last Name:HENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 YARDELL RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-8883
Mailing Address - Country:US
Mailing Address - Phone:870-577-1057
Mailing Address - Fax:
Practice Address - Street 1:5050 YARDELL RD
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-8883
Practice Address - Country:US
Practice Address - Phone:870-577-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR931113628171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator