Provider Demographics
NPI:1538319645
Name:HENLEY, MEARA E (NP)
Entity Type:Individual
Prefix:DR
First Name:MEARA
Middle Name:E
Last Name:HENLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:DR
Other - First Name:MEARA
Other - Middle Name:E
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:150 VALPREDA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2973
Mailing Address - Country:US
Mailing Address - Phone:760-736-6767
Mailing Address - Fax:760-736-8740
Practice Address - Street 1:150 VALPREDA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2973
Practice Address - Country:US
Practice Address - Phone:760-736-6767
Practice Address - Fax:760-736-6767
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156362-30163WP0200X
WI3538-33363LP0200X
CA95002545363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1538319645Medicaid
WI156362-30OtherRN LICENSE
WI1538319645Medicaid