Provider Demographics
NPI:1164149662
Name:HENKIN, ROSE JENNA (CNIM)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:JENNA
Last Name:HENKIN
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 WYNNSTONE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2894
Mailing Address - Country:US
Mailing Address - Phone:734-355-4671
Mailing Address - Fax:
Practice Address - Street 1:1355 WYNNSTONE DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2894
Practice Address - Country:US
Practice Address - Phone:734-355-4671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5113246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5113OtherCNIM