Provider Demographics
NPI:1518203355
Name:HENRY, MARY JANE ROMONA (LPN)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:ROMONA
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 1:1617 AUPUNI ST
Mailing Address - Street 2:APT K
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-1980
Mailing Address - Country:US
Mailing Address - Phone:808-349-7902
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:BLDG 1750, RM 158A
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:888-888-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI6821164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse