Provider Demographics
NPI:1043599111
Name:HENLEY, ROSHONTAE (LVN)
Entity Type:Individual
Prefix:MISS
First Name:ROSHONTAE
Middle Name:
Last Name:HENLEY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:MISS
Other - First Name:ROSHONTAE
Other - Middle Name:
Other - Last Name:HENLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:280 PARKVIEW TERRACE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 PARK VIEW TER
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4570
Practice Address - Country:US
Practice Address - Phone:510-466-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2012-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN226538164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse