Provider Demographics
NPI:1841743911
Name:HENRY, TAMARA M (FNP)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 RIVER MEWS LN
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-3113
Mailing Address - Country:US
Mailing Address - Phone:516-655-3684
Mailing Address - Fax:
Practice Address - Street 1:6 GRAMATAN AVE STE 625
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3208
Practice Address - Country:US
Practice Address - Phone:201-654-1531
Practice Address - Fax:201-643-6645
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF04293-01363LP0808X
NY340690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04830113Medicaid