Healthcare Provider Details

I. General information

NPI: 1861549685
Provider Name (Legal Business Name): SHANA MARIE HENNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANA MARIE WALTON MD

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

450 E 96TH ST STE 200
INDIANAPOLIS IN
46240-3797
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01066872A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: