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
StateLicense IDTaxonomies
NJ26RN18111600163W00000X
NY574808-1163W00000X
NJ26NJ00927600363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner