MEDICARE: MRS. CASSIDY HENSLEY FNP-BC

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	363LF0000X	Family Nurse Practitioner	0024171512	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VVD228B667	OTHER	VA	PTAN
2	DN2980	OTHER		GROUP PTAN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	261083931	OTHER		TAX ID
5	C10361	OTHER		GROUP ORGANIZATION PTAN

General Provider Information

NPI Number	:	1124443957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CASSIDY HENSLEY FNP-BC

Provider Business Mailing Address
First Line	:	7021 W LEE HWY
Second Line	:	SUITE C
City	:	RURAL RETREAT
State	:	VA
Zip	:	24368-2933
Country	:	US
Telephone Number	:	866-595-3662
Fax Number	:	276-686-6046

Provider Business Practice Location Address
First Line	:	7021 W LEE HWY
Second Line	:	SUITE C
City	:	RURAL RETREAT
State	:	VA
Zip	:	24368-2933
Country	:	US
Telephone Number	:	866-595-3662
Fax Number	:	276-686-6046

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

Provider Enumeration Date	:	03/04/2014
Last Update Date	:	12/18/2018

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