Healthcare Provider Details

I. General information

NPI: 1649745530
Provider Name (Legal Business Name): DEIDRA DIANE HENLEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 UNIVERSITY PKWY STE 1550
AIKEN SC
29801-6838
US

IV. Provider business mailing address

2946 AYLESBURY DR
AUGUSTA GA
30909-0628
US

V. Phone/Fax

Practice location:
  • Phone: 803-649-7535
  • Fax: 803-648-8771
Mailing address:
  • Phone: 803-640-8094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN205120
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: