Basic Information
| Provider Information | |||||||||
| NPI: | 1912972779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENICK | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | ALYCE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 SANTA MONICA BLVD. | ||||||||
| Address2: | SUITE 400E | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900643205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104535654 | ||||||||
| FaxNumber: | 3104536885 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 SANTA MONICA BLVD | ||||||||
| Address2: | SUITE 400E | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104535654 | ||||||||
| FaxNumber: | 3104536885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | G78994 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | G78994 | 01 | CA | CALIFORNIA LICENSE | OTHER | BH4317194 | 01 | CA | DEA NUMBER | OTHER | G789940 | 05 | CA | MEDICAID | GR0085740 | 05 | CA | MEDICAID |