Provider Demographics
NPI:1447407077
Name:HENRY, TIFANNIE (LPN)
Entity Type:Individual
Prefix:
First Name:TIFANNIE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-2806
Mailing Address - Country:US
Mailing Address - Phone:631-729-6264
Mailing Address - Fax:
Practice Address - Street 1:124 BEAVER DR
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-2806
Practice Address - Country:US
Practice Address - Phone:631-729-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282445164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse