Provider Demographics
NPI:1831273515
Name:HENRY, SANDRA R (ANP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:HENRY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:R
Other - Last Name:GULLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:2900 LEMAY FERRY RD
Mailing Address - Street 2:STE 104
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-3900
Mailing Address - Country:US
Mailing Address - Phone:314-525-1887
Mailing Address - Fax:314-525-1868
Practice Address - Street 1:2900 LEMAY FERRY RD
Practice Address - Street 2:STE 104
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3900
Practice Address - Country:US
Practice Address - Phone:314-525-1887
Practice Address - Fax:314-525-1868
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104685363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427423306Medicaid
MO828950247Medicare ID - Type Unspecified
Q64229Medicare UPIN