Provider Demographics
NPI:1164497988
Name:HENINGER, RANDY S (CNM)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:HENINGER
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 S 4225 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-6896
Mailing Address - Country:US
Mailing Address - Phone:801-540-7100
Mailing Address - Fax:801-820-6955
Practice Address - Street 1:1492 W ANTELOPE DR STE 206
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1150
Practice Address - Country:US
Practice Address - Phone:801-776-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5701141-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife