Provider Demographics
NPI:1083629588
Name:HENNINGER, AMY KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KATHERINE
Last Name:HENNINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NE 8TH ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7317
Mailing Address - Country:US
Mailing Address - Phone:503-988-5155
Mailing Address - Fax:503-988-5185
Practice Address - Street 1:421 SW OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1817
Practice Address - Country:US
Practice Address - Phone:503-988-7458
Practice Address - Fax:503-988-3015
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR096511Medicaid
OR132009Medicaid
H16841Medicare UPIN
OR132009Medicaid