Provider Demographics
NPI:1255875167
Name:HENRY, ANGELLA E (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ANGELLA
Middle Name:E
Last Name:HENRY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 BAYWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4125
Mailing Address - Country:US
Mailing Address - Phone:201-417-7066
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 201
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3256
Practice Address - Country:US
Practice Address - Phone:770-812-3839
Practice Address - Fax:770-456-3785
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171201363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily