Provider Demographics
NPI:1346918786
Name:HENRY, MICHAEL LEWIS (NP-C, ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEWIS
Last Name:HENRY
Suffix:
Gender:M
Credentials:NP-C, ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 PEACE ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-6219
Mailing Address - Country:US
Mailing Address - Phone:757-777-8316
Mailing Address - Fax:
Practice Address - Street 1:979 E 3RD ST STE C-820
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-778-9001
Practice Address - Fax:423-778-4692
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026468363LA2100X
TN30077363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN30077Medicaid