Healthcare Provider Details

I. General information

NPI: 1720086127
Provider Name (Legal Business Name): BONNY DAWN HENNING O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 W MAIN ST
NEWARK OH
43055-1135
US

IV. Provider business mailing address

6607 CLARK STATE RD
BLACKLICK OH
43004-9657
US

V. Phone/Fax

Practice location:
  • Phone: 614-257-5200
  • Fax:
Mailing address:
  • Phone: 614-204-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4745
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOH4745/T1549
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: