Provider Demographics
NPI:1245326347
Name:HENRY, MYRTLE A (ARNP)
Entity type:Individual
Prefix:
First Name:MYRTLE
Middle Name:A
Last Name:HENRY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 862851
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-2851
Mailing Address - Country:US
Mailing Address - Phone:954-847-4273
Mailing Address - Fax:954-847-4245
Practice Address - Street 1:303 SE 17TH ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2523
Practice Address - Country:US
Practice Address - Phone:954-355-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1145942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7856OtherBCBS
FLY7856OtherBCBS
S76168Medicare UPIN