Provider Demographics
NPI:1942454269
Name:HENRY, ETHEL M (PA)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10692 CRESTWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4410
Mailing Address - Country:US
Mailing Address - Phone:703-368-9131
Mailing Address - Fax:703-368-2038
Practice Address - Street 1:10692 CRESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4410
Practice Address - Country:US
Practice Address - Phone:703-368-9131
Practice Address - Fax:703-368-2038
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110840684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical