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General NPI Number Information
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NPI Number | 1982699070
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Entity Type | Individual
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Provider Name | DIANE M HENRY PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/14/2005
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 210 1ST ST N BOX 67
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City | BERTHA
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State | MN
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Zip | 56437-0067
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Country | US
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Telephone | 218-924-2250
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Fax | 218-924-2257
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Provider Business Mailing Address
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Address Line | 1771 COUNTY ROAD 120 NE
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City | ALEXANDRIA
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State | MN
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Zip | 56308-8009
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Country | US
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Telephone | 320-846-8171
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9263
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License Number State | MN
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