Healthcare Provider Details

I. General information

NPI: 1194416297
Provider Name (Legal Business Name): KOLEA TWAYETTE HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 14335
IRVINE CA
92623-4335
US

IV. Provider business mailing address

PO BOX 14335
IRVINE CA
92623-4335
US

V. Phone/Fax

Practice location:
  • Phone: 941-993-3569
  • Fax: 323-693-7157
Mailing address:
  • Phone: 941-993-3569
  • Fax: 323-693-7157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95146429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: