Provider Demographics
NPI:1225743719
Name:HENRY, LYDIA MICHELLE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MICHELLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 S HIGHLAND ST APT 126
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-1562
Mailing Address - Country:US
Mailing Address - Phone:251-802-3590
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program