Provider Demographics
NPI:1700047214
Name:HENRIQUEZ, JOHANNA (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:
Last Name:HENRIQUEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WALL ST W
Mailing Address - Street 2:#4105
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-3514
Mailing Address - Country:US
Mailing Address - Phone:201-214-3813
Mailing Address - Fax:
Practice Address - Street 1:1301 WALL ST W
Practice Address - Street 2:#4105
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-3514
Practice Address - Country:US
Practice Address - Phone:201-214-3813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS17767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program