MEDICARE: VIVIAN HENRY 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	163W00000X	Registered Nurse	4704119497	MI

General Provider Information

NPI Number	:	1306586540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN HENRY RN

Provider Business Mailing Address
First Line	:	28460 VILLA CT N
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2436
Country	:	US
Telephone Number	:	248-794-0825
Fax Number	:

Provider Business Practice Location Address
First Line	:	882 OAKMAN BLVDS
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48238
Country	:	US
Telephone Number	:	313-569-7231
Fax Number	:

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

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	01/18/2026

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