Provider Demographics
NPI:1194069609
Name:HENRY, KELLEY VERONICA (RN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:VERONICA
Last Name:HENRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 NEW LOTS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207
Mailing Address - Country:US
Mailing Address - Phone:347-822-0712
Mailing Address - Fax:
Practice Address - Street 1:2037 UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234
Practice Address - Country:US
Practice Address - Phone:718-951-9009
Practice Address - Fax:718-951-9719
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311257164W00000X
NY823118163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse