Provider Demographics
NPI:1518998707
Name:HENRY, LESLIE WINIFRED (FNP)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WINIFRED
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 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2911
Practice Address - Fax:207-662-6308
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167557363LF0000X
MECNP81749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000980Medicaid
NCC9727OtherMEDCOST PROVIDER#
NCP00237178OtherPALMETTO GBA PROVIDER#
NCFH4000395OtherFIRSTCAROLINACARE PROV.#
SCNP0951OtherSC MEDICAID PROVIDER#
P99832Medicare UPIN
NCC9727OtherMEDCOST PROVIDER#
NCP00237178OtherPALMETTO GBA PROVIDER#
SCNP0951OtherSC MEDICAID PROVIDER#