=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689757155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATTY KRISTAL HENRY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 E TOLLISON ST
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31513-0120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-367-0434
-----------------------------------------------------
Fax | 912-367-0436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2070
-----------------------------------------------------
City | BAXLEY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31515-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-367-0434
-----------------------------------------------------
Fax | 912-367-0436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 35077380
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 060851
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------