Provider Demographics
NPI:1063268084
Name:HENRY, CORTINA M
Entity type:Individual
Prefix:
First Name:CORTINA
Middle Name:M
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 1:20826 NE OAK ST
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-4792
Mailing Address - Country:US
Mailing Address - Phone:850-766-2995
Mailing Address - Fax:
Practice Address - Street 1:20798 NE OAK ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-4731
Practice Address - Country:US
Practice Address - Phone:850-766-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist