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General NPI Number Information
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NPI Number | 1215988852
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Entity Type | Individual
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Provider Name | MICHELLE D HENNEBERRY PMHNP
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Gender | Female
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 12/17/2009
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Provider Practice Location Address
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Address Line | 263 STATE ST SUITE 23
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City | BANGOR
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State | ME
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Zip | 04401-5435
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Country | US
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Telephone | 207-945-3615
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Fax | 207-945-3444
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Provider Business Mailing Address
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Address Line | 263 STATE ST SUITE 23
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City | BANGOR
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State | ME
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Zip | 04401-5435
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Country | US
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Telephone | 207-945-3615
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Fax | 207-945-3444
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | R037051
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License Number State | ME
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