Basic Information
| Provider Information | |||||||||
| NPI: | 1104879592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSEN | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 44TH ST SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495085008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7782 20TH AVE | ||||||||
| Address2: | |||||||||
| City: | JENISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494288524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858700 | ||||||||
| FaxNumber: | 6164575567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301072799 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4311439 | 05 | MI | MEDICAID | 4320797 | 05 | MI | MEDICAID | 4308021 | 05 | MI | MEDICAID | 4877231 | 05 | MI | MEDICAID |