1841743911 NPI number — TAMARA M HENRY FNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841743911 NPI number — TAMARA M HENRY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
TAMARA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841743911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 RIVER MEWS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDGEWATER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07020-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-655-3684
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 GRAMATAN AVE STE 625
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10550-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-654-1531
Provider Business Practice Location Address Fax Number:
201-643-6645
Provider Enumeration Date:
07/25/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  F04293-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 340690 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04830113 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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