Provider Demographics
NPI:1174627814
Name:HENSLEY, KELLEY NICOLE (DC)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:NICOLE
Last Name:HENSLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SEA GROVE WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-4831
Mailing Address - Country:US
Mailing Address - Phone:479-721-5824
Mailing Address - Fax:
Practice Address - Street 1:310 THIRD ST STE B
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1834
Practice Address - Country:US
Practice Address - Phone:850-227-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14359111N00000X
AR1706111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
44903662001OtherBLUE CROSS BLUE SHIELD
44903662001OtherBLUE CROSS BLUE SHIELD
U62861Medicare UPIN