Provider Demographics
NPI:1811407661
Name:HENRY, MARCIA M (LPN)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 TALON CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4518
Mailing Address - Country:US
Mailing Address - Phone:407-738-5716
Mailing Address - Fax:407-201-2999
Practice Address - Street 1:1632 TALON CT
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-4518
Practice Address - Country:US
Practice Address - Phone:407-738-5716
Practice Address - Fax:407-201-2999
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1167131164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPN1167131OtherDOH