Provider Demographics
NPI:1083879308
Name:HENNIG, CECILIA BERNADETTE (RD,LD/N,CDE)
Entity Type:Individual
Prefix:MS
First Name:CECILIA
Middle Name:BERNADETTE
Last Name:HENNIG
Suffix:
Gender:F
Credentials:RD,LD/N,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHIRCLIFF WAY
Mailing Address - Street 2:SUITE 1830
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4748
Mailing Address - Country:US
Mailing Address - Phone:904-308-8794
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:SUITE 1830
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-8794
Practice Address - Fax:904-308-2958
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND65133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered