Provider Demographics
NPI:1417054982
Name:HENRY, ANGELA LYN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYN
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 1:1103 VILLAGE SQUARE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-1762
Mailing Address - Country:US
Mailing Address - Phone:419-872-3213
Mailing Address - Fax:419-872-9549
Practice Address - Street 1:1103 VILLAGE SQUARE DR STE 100
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1762
Practice Address - Country:US
Practice Address - Phone:419-872-3213
Practice Address - Fax:419-872-9549
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 09014-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9276581Medicare ID - Type UnspecifiedNCNWO