Provider Demographics
NPI:1285817411
Name:HENNINGHAM, DANIELLE RENEE
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:RENEE
Last Name:HENNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 CORTLAND DR
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-9651
Mailing Address - Country:US
Mailing Address - Phone:716-908-5950
Mailing Address - Fax:
Practice Address - Street 1:2325 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1819
Practice Address - Country:US
Practice Address - Phone:716-773-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01083765Medicaid