Provider Demographics
NPI:1649565482
Name:HENRY, KRISTINE (LDN)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 CHESAPEAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6395
Mailing Address - Country:US
Mailing Address - Phone:410-398-3868
Mailing Address - Fax:
Practice Address - Street 1:137 W HIGH ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-8604
Practice Address - Country:US
Practice Address - Phone:410-620-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02157133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist