Provider Demographics
NPI:1871340893
Name:HENRY, NICHOLE (CMF)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 PENNEY WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0937
Mailing Address - Country:US
Mailing Address - Phone:530-410-8093
Mailing Address - Fax:
Practice Address - Street 1:6620 COYLE AVE STE 301
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6337
Practice Address - Country:US
Practice Address - Phone:916-671-3417
Practice Address - Fax:916-241-9344
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC70683224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter