Provider Demographics
NPI:1356014880
Name:HENRY, COURTNEY BRELAND (FNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BRELAND
Last Name:HENRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4594
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-4594
Mailing Address - Country:US
Mailing Address - Phone:228-273-4096
Mailing Address - Fax:228-594-1765
Practice Address - Street 1:180B DEBUYS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4404
Practice Address - Country:US
Practice Address - Phone:228-273-4096
Practice Address - Fax:228-594-1765
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904549363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS009074805Medicaid