Provider Demographics
NPI:1548334253
Name:HENRY, DELORES MARIE
Entity type:Individual
Prefix:
First Name:DELORES
Middle Name:MARIE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DELORES
Other - Middle Name:MARIE
Other - Last Name:POITIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6375 GREEN VALLEY CIR UNIT 312
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-8059
Mailing Address - Country:US
Mailing Address - Phone:310-222-3714
Mailing Address - Fax:
Practice Address - Street 1:1124 W CARSON ST # N28
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2006
Practice Address - Country:US
Practice Address - Phone:310-222-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA205315163WA0400X
CA2093363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Not Answered363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health