Provider Demographics
NPI:1770025603
Name:HENRY, JOHN C (FNP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:HENRY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W CLAY STREET
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4368
Mailing Address - Country:US
Mailing Address - Phone:217-431-7200
Mailing Address - Fax:217-431-8000
Practice Address - Street 1:1010 W CLAY STREET
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4368
Practice Address - Country:US
Practice Address - Phone:217-431-7200
Practice Address - Fax:217-431-8000
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014897363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209014897OtherLIC NUMBER