Provider Demographics
NPI:1104107804
Name:HENRY, EUN JOO K (LICENSED PRACT NURS)
Entity type:Individual
Prefix:MRS
First Name:EUN JOO
Middle Name:K
Last Name:HENRY
Suffix:
Gender:F
Credentials:LICENSED PRACT NURS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-1031
Mailing Address - Country:US
Mailing Address - Phone:315-573-0278
Mailing Address - Fax:
Practice Address - Street 1:9 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-1031
Practice Address - Country:US
Practice Address - Phone:315-573-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258077-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse