Provider Demographics
NPI:1902456650
Name:HENRY, MISTIQUE CHANTAY (APRN)
Entity Type:Individual
Prefix:
First Name:MISTIQUE
Middle Name:CHANTAY
Last Name:HENRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-5403
Mailing Address - Country:US
Mailing Address - Phone:614-566-4414
Mailing Address - Fax:
Practice Address - Street 1:3820 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-5403
Practice Address - Country:US
Practice Address - Phone:614-566-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025613363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health