Provider Demographics
NPI:1679816870
Name:HENRY, VALENCIA JOYCE (DNP)
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:JOYCE
Last Name:HENRY
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 RIVER OAKS DR STE 6
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6674
Mailing Address - Country:US
Mailing Address - Phone:860-951-5450
Mailing Address - Fax:
Practice Address - Street 1:1705 N OAK ST STE 2
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3580
Practice Address - Country:US
Practice Address - Phone:843-507-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005324363L00000X, 363LF0000X
MDR203517363LF0000X
SC22494363LP2300X
NC5010395363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004053245Medicaid