Provider Demographics
NPI:1730105636
Name:HENRY, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1913
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-1913
Mailing Address - Country:US
Mailing Address - Phone:209-742-6162
Mailing Address - Fax:209-742-6163
Practice Address - Street 1:5034 COAKLEY CIRCLE
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338
Practice Address - Country:US
Practice Address - Phone:209-742-6224
Practice Address - Fax:209-966-7848
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100458332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME00572FMedicaid
CADME00572FMedicaid