Healthcare Provider Details

I. General information

NPI: 1225564073
Provider Name (Legal Business Name): MICHELLE HENNE, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5421 S FLORIDA AVE
LAKELAND FL
33813-2523
US

IV. Provider business mailing address

5421 S FLORIDA AVE
LAKELAND FL
33813-2523
US

V. Phone/Fax

Practice location:
  • Phone: 863-401-4401
  • Fax: 866-824-2717
Mailing address:
  • Phone: 863-401-4401
  • Fax: 866-824-2717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberME121120
License Number StateFL

VIII. Authorized Official

Name: MICHELLE HENNE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 321-759-2562