Provider Demographics
NPI: | 1629610167 |
---|---|
Name: | HENRY, TANISHA P (MSN, APRN, FNP-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | TANISHA |
Middle Name: | P |
Last Name: | HENRY |
Suffix: | |
Gender: | F |
Credentials: | MSN, APRN, FNP-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 1276 |
Mailing Address - Street 2: | |
Mailing Address - City: | BALDWIN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11510-0876 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 516-417-6797 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1312 GRAND AVE |
Practice Address - Street 2: | |
Practice Address - City: | NORTH BALDWIN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11510-1418 |
Practice Address - Country: | US |
Practice Address - Phone: | 516-417-6797 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2019-10-16 |
Last Update Date: | 2019-10-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | 26RN18111600 | 163W00000X |
NY | 574808-1 | 163W00000X |
NJ | 26NJ00927600 | 363L00000X, 363LP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No | 163W00000X | Nursing Service Providers | Registered Nurse | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |