Provider Demographics
NPI:1053704668
Name:HENRY, OLEN (NP)
Entity type:Individual
Prefix:MR
First Name:OLEN
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 DELMAS TER
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2713
Mailing Address - Country:US
Mailing Address - Phone:310-202-4745
Mailing Address - Fax:323-402-0860
Practice Address - Street 1:3828 DELMAS TER
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2713
Practice Address - Country:US
Practice Address - Phone:310-202-4745
Practice Address - Fax:323-402-0860
Is Sole Proprietor?:No
Enumeration Date:2015-03-07
Last Update Date:2015-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524935163WE0003X
CA11003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency