Healthcare Provider Details

I. General information

NPI: 1780658617
Provider Name (Legal Business Name): JANE ELLEN HENRY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 STATE ROAD 206 WEST
ST AUGUSTINE FL
32086
US

IV. Provider business mailing address

580 STATE ROAD 206 WEST
ST AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 954-695-3643
  • Fax: 954-695-3643
Mailing address:
  • Phone: 954-695-3643
  • Fax: 954-695-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3000182
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: