Basic Information
| Provider Information | |||||||||
| NPI: | 1205386786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | AMBER | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11217 HIGHWAY 421 S | ||||||||
| Address2: | |||||||||
| City: | TYNER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404868352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6067121200 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 MARIE LANGDON DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065985104 | ||||||||
| FaxNumber: | 6065980983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3010627 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 3010627 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 13941965 | 01 | CAQH | OTHER | MS4473966 | 01 | DEA | OTHER | 7100437810 | 05 | KY | MEDICAID |