Provider Demographics
NPI:1316529795
Name:HENRY, ALYX CORNELIA (MPH, RDN, CDN, LDN)
Entity type:Individual
Prefix:
First Name:ALYX
Middle Name:CORNELIA
Last Name:HENRY
Suffix:
Gender:F
Credentials:MPH, RDN, CDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3564 AVALON PARK BLVD E STE 1A944
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7365
Mailing Address - Country:US
Mailing Address - Phone:562-416-9621
Mailing Address - Fax:
Practice Address - Street 1:20430 NEEDLETREE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3487
Practice Address - Country:US
Practice Address - Phone:562-416-9621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-25
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86151899133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered