=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003879735
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANISHA M HENRY PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2006
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 SAN PABLO RD S VINCENT STABILE BLDG 550N
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-953-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 SAN PABLO RD S VINCENT STABILE BLDG 550N
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-953-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 0110010456
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 029626
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA62280
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 724323
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | AMD1403
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 085009476
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9103457
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------