Provider Demographics
NPI:1063574101
Name:HENRY, ANTONIA JOCELYN (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIA
Middle Name:JOCELYN
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2093 HEALTH DR SW STE 302
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9691
Mailing Address - Country:US
Mailing Address - Phone:616-252-5775
Mailing Address - Fax:616-252-5269
Practice Address - Street 1:2093 HEALTH DR SW STE 302
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9691
Practice Address - Country:US
Practice Address - Phone:616-252-5775
Practice Address - Fax:616-252-5269
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229207208600000X
MI4301501661208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301501661OtherMEDICAL LICENSE