Provider Demographics
NPI:1609632942
Name:HENRY, MELISSANDRE (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSANDRE
Middle Name:
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 1:3750 SW MANAK ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7705
Mailing Address - Country:US
Mailing Address - Phone:772-834-6965
Mailing Address - Fax:
Practice Address - Street 1:3750 SW MANAK ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7705
Practice Address - Country:US
Practice Address - Phone:772-834-6965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031477363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily