Healthcare Provider Details

I. General information

NPI: 1356060941
Provider Name (Legal Business Name): HEATHER M HENNING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KAMANI ST
PAHALA HI
96777
US

IV. Provider business mailing address

PO BOX 1064
VOLCANO HI
96785-1064
US

V. Phone/Fax

Practice location:
  • Phone: 920-209-3602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD-1353
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: