Provider Demographics
NPI:1659990521
Name:HENRY, NICKSON
Entity Type:Individual
Prefix:
First Name:NICKSON
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 PORTOFINO WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-8174
Mailing Address - Country:US
Mailing Address - Phone:754-368-6743
Mailing Address - Fax:
Practice Address - Street 1:4700 PORTOFINO WAY APT 201
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-8174
Practice Address - Country:US
Practice Address - Phone:754-368-6743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-0007342083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine