Provider Demographics
NPI:1366793457
Name:HENRY, ADENA URSULA
Entity type:Individual
Prefix:MISS
First Name:ADENA
Middle Name:URSULA
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1901
Mailing Address - Country:US
Mailing Address - Phone:208-420-6231
Mailing Address - Fax:
Practice Address - Street 1:129 4TH AVE E
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1901
Practice Address - Country:US
Practice Address - Phone:208-420-6231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide