Healthcare Provider Details

I. General information

NPI: 1376143271
Provider Name (Legal Business Name): LYNETTE HENLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5422 SHARSWOOD ST
PHILADELPHIA PA
19131-3929
US

IV. Provider business mailing address

5422 SHARSWOOD ST
PHILADELPHIA PA
19131-3929
US

V. Phone/Fax

Practice location:
  • Phone: 267-439-4656
  • Fax: 215-477-2476
Mailing address:
  • Phone: 267-439-4656
  • Fax: 215-477-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: