Provider Demographics
NPI:1346873817
Name:HENRY, TANISHA (RN)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10380 SW VILLAGE CENTER DR # 188
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-1931
Mailing Address - Country:US
Mailing Address - Phone:772-240-9417
Mailing Address - Fax:772-673-8228
Practice Address - Street 1:1833 SW CAPEHART AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4606
Practice Address - Country:US
Practice Address - Phone:772-240-9417
Practice Address - Fax:772-673-8228
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9481114251E00000X, 3747P1801X, 385H00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385H00000XRespite Care FacilityRespite Care