Provider Demographics
NPI:1023024734
Name:HENNEN, DEBORAH (PA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:HENNEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3277
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20918-3277
Mailing Address - Country:US
Mailing Address - Phone:301-681-1585
Mailing Address - Fax:
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1483
Practice Address - Country:US
Practice Address - Phone:301-754-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCOOO1429363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD018317P80Medicare ID - Type Unspecified