Healthcare Provider Details

I. General information

NPI: 1396078739
Provider Name (Legal Business Name): MRS. JUDY L HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 STATE ROUTE 4 LOT 1 BOX 51
WHITEHALL NY
12887-2323
US

IV. Provider business mailing address

9850 STATE ROUTE 4 LOT 1 BOX 51
WHITEHALL NY
12887-2323
US

V. Phone/Fax

Practice location:
  • Phone: 518-824-1199
  • Fax: 518-824-1199
Mailing address:
  • Phone: 518-824-1199
  • Fax: 518-824-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number555086-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: