MEDICARE: ANNETTE LAQUETA HENLEY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	903378	MS
2	363LF0000X	Family Nurse Practitioner	906994	MS

General Provider Information

NPI Number	:	1063098804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNETTE LAQUETA HENLEY RN

Provider Business Mailing Address
First Line	:	92 FIRST COLONY CIR
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-7900
Country	:	US
Telephone Number	:	662-251-3188
Fax Number	:

Provider Business Practice Location Address
First Line	:	92 FIRST COLONY CIR
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39702-7900
Country	:	US
Telephone Number	:	662-251-3188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2021
Last Update Date	:	10/14/2024

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