Provider Demographics
NPI:1730658493
Name:HENRY, EMILY NICOLE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:NICOLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5137 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-9031
Mailing Address - Country:US
Mailing Address - Phone:907-821-1340
Mailing Address - Fax:
Practice Address - Street 1:97 EICHNER AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-9033
Practice Address - Country:US
Practice Address - Phone:907-821-1340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-24
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK140329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered