Provider Demographics
NPI:1043390529
Name:HENRY, LILLIAN (ANP)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 PACKARD ST
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2051
Mailing Address - Country:US
Mailing Address - Phone:866-645-5578
Mailing Address - Fax:888-528-0919
Practice Address - Street 1:3830 PACKARD ST
Practice Address - Street 2:SUITE 180
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2051
Practice Address - Country:US
Practice Address - Phone:866-645-5578
Practice Address - Fax:888-528-0919
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704187950363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4730660Medicaid
MICJ6987OtherTRAVELERS
MIP00236438OtherTRAVELERS
MIQ44745Medicare UPIN
MICJ6987OtherTRAVELERS
P17200001Medicare PIN