Provider Demographics
NPI:1134455520
Name:HENRY, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1743
Practice Address - Country:US
Practice Address - Phone:860-739-0348
Practice Address - Fax:860-739-6779
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN284697363LF0000X
CT4428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily