Basic Information
Provider Information | |||||||||
NPI: | 1538319645 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENLEY | ||||||||
FirstName: | MEARA | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PETERSON | ||||||||
OtherFirstName: | MEARA | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 150 VALPREDA RD | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607366767 | ||||||||
FaxNumber: | 7607368740 | ||||||||
Practice Location | |||||||||
Address1: | 150 VALPREDA RD | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607366767 | ||||||||
FaxNumber: | 7607366767 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2008 | ||||||||
LastUpdateDate: | 08/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 156362-30 | WI | N |   | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0200X | 3538-33 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 95002545 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 1538319645 | 05 | WI |   | MEDICAID | 156362-30 | 01 | WI | RN LICENSE | OTHER |