Healthcare Provider Details

I. General information

NPI: 1932616257
Provider Name (Legal Business Name): JOANNA MARIE HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON ST
ELMIRA NY
14901-2849
US

IV. Provider business mailing address

1101 SEXTON HOLLOW RD
PAINTED POST NY
14870-9420
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-4890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number705656
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: