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Tanisha M Henry

Physician Assistant

Physician Assistants & Advanced Practice Nursing Providers

4500 San Pablo Rd S, Vincent Stabile Bldg 550n, Jacksonville, FL 32224-1865

(904) 953-2000

PECOS Enrollment

This provider is enrolled in PECOS as TANISHA HENRY.

Based on the most recent information from CMS, provider Tanisha M Henry is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.

Part B
Medicare Part B
Enrolled
HHA
Home Health Agency
Enrolled
DME
Durable Medical Equipment
Enrolled
PMD
Power Mobility Device
Enrolled

CMS last updated its PECOS records 2 days ago.

Profile Details

Provider ID
1003879735
Provider Type
Individual
Full Name
Henry, Tanisha M
Title
Ms.
Credential
PA

Gender
Female
Sole Proprietor
No
Enumeration Date
4/12/2006
Last Updated
12/18/2024

Contact Information

Practice Location

4500 San Pablo Rd S, Vincent Stabile Bldg 550n, Jacksonville, FL 32224-1865

(904) 953-2000

Unlisted Fax

Mailing Location

4500 San Pablo Rd S, Vincent Stabile Bldg 550n, Jacksonville, FL 32224-1865

(904) 953-2000

Unlisted Fax

Provider Taxonomies

Code	Description	License
Code 363AM0700X Primary	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License PA9103457 Florida
Code 363AM0700X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License 0110010456 Virginia
Code 363AM0700X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License 029626 New York
Code 363AM0700X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License PA62280 California
Code 363AM0700X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License 724323 Wisconsin
Code 363AM0700X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License AMD1403 Hawaii
Code 363AM0700X	Description Physician Assistant Physician Assistants & Advanced Practice Nursing Providers	License 085009476 Illinois

Provider Identifiers

ID	Description	Issuer
ID 417531260A	Description Medicaid	Issuer Unlisted Georgia
ID 2922835-00	Description Medicaid	Issuer Unlisted Florida

Tanisha M Henry

PECOS Enrollment

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