Individual
KELLIE LAWRENCE HENDERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1508 TOMBRAS AVE, EAST RIDGE, TN 37412-2720
(423) 867-4969
(423) 867-4971
Mailing address
1508 TOMBRAS AVE, EAST RIDGE, TN 37412-2720
(423) 867-4969
(423) 867-4971
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA0000001098
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4219886
BCBS- TENNESSEE
TN
05
—
Q007546
—
TN
Enumeration date
08/23/2006
Last updated
08/05/2015
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