Provider Demographics
NPI:1730652611
Name:HENRY, MICHELLE ROBERTSON
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ROBERTSON
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 1:13759 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3984
Mailing Address - Country:US
Mailing Address - Phone:954-303-8600
Mailing Address - Fax:
Practice Address - Street 1:13759 SW 32ND ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3984
Practice Address - Country:US
Practice Address - Phone:954-303-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3353102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily