Provider Demographics
NPI:1649745530
Name:HENLEY, DEIDRA DIANE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:DIANE
Last Name:HENLEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2946 AYLESBURY DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0628
Mailing Address - Country:US
Mailing Address - Phone:803-640-8094
Mailing Address - Fax:
Practice Address - Street 1:2806 HILLCREEK DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6484
Practice Address - Country:US
Practice Address - Phone:706-863-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205120363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily