Provider Demographics
NPI:1952388811
Name:HENRY, WILLETTA (FNP)
Entity Type:Individual
Prefix:
First Name:WILLETTA
Middle Name:
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 1:10330 ROAD 375
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-656-0226
Mailing Address - Fax:601-656-0226
Practice Address - Street 1:10330 ROAD 375
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350
Practice Address - Country:US
Practice Address - Phone:601-656-0226
Practice Address - Fax:601-656-0226
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR571121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
500003615OtherRAILROAD MEDICARE
MS00110039Medicaid
500003615OtherRAILROAD MEDICARE
P96857Medicare UPIN