Healthcare Provider Details

I. General information

NPI: 1134455520
Provider Name (Legal Business Name): ELIZABETH HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 FLANDERS RD
EAST LYME CT
06333-1743
US

IV. Provider business mailing address

7 VILLAGE CT
EAST LYME CT
06333-1200
US

V. Phone/Fax

Practice location:
  • Phone: 860-739-0348
  • Fax: 860-739-6779
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN284697
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4428
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: