Provider Demographics
NPI:1770636193
Name:HENRY, MICHELLE MARIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:HENRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:SEMAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:20 FELICITY LN
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6101
Mailing Address - Country:US
Mailing Address - Phone:860-489-4144
Mailing Address - Fax:860-489-4412
Practice Address - Street 1:20 FELICITY LN
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6101
Practice Address - Country:US
Practice Address - Phone:860-489-4144
Practice Address - Fax:860-489-4412
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE59540163W00000X
CT003250363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
030250OtherCT CARE
358978OtherPREFERRED ONE