Provider Demographics
NPI:1508132085
Name:HENRY, ROSANNE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSANNE
Middle Name:MARIE
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 CENTURY MEDICAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2100
Mailing Address - Country:US
Mailing Address - Phone:321-268-6264
Mailing Address - Fax:321-268-6273
Practice Address - Street 1:5005 PORT ST JOHN PKWY STE 2300
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4305
Practice Address - Country:US
Practice Address - Phone:321-633-8663
Practice Address - Fax:321-633-8618
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127424207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017624200Medicaid
FLIP545ZMedicare UPIN