Provider Demographics
NPI:1144406786
Name:BASANTA-HENRY, PATRICE LEONIE (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:LEONIE
Last Name:BASANTA-HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BEAVER RUIN RD NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3401
Mailing Address - Country:US
Mailing Address - Phone:770-279-3838
Mailing Address - Fax:
Practice Address - Street 1:625 BEAVER RUIN RD NW
Practice Address - Street 2:SUITE D
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:770-279-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60556207VM0101X
GA000368207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology