Healthcare Provider Details

I. General information

NPI: 1275064776
Provider Name (Legal Business Name): SENNA RAE MUNNIKHUYSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST STE C400
LEXINGTON KY
40536-0010
US

IV. Provider business mailing address

1800 ORLEANS ST STE 11379
BALTIMORE MD
21287-0010
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-4554
  • Fax: 859-257-8978
Mailing address:
  • Phone: 410-955-8751
  • Fax: 410-955-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0089359
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR4564
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number58108
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: