Healthcare Provider Details

I. General information

NPI: 1285405316
Provider Name (Legal Business Name): LAQUEENTHA HENRY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 MAIN ST
OVID NY
14521-9401
US

IV. Provider business mailing address

601B W WASHINGTON ST
GENEVA NY
14456-2119
US

V. Phone/Fax

Practice location:
  • Phone: 607-403-0065
  • Fax:
Mailing address:
  • Phone: 315-781-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number313050
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number702290
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: