Provider Demographics
NPI:1407887730
Name:HENNEKES, GAYLE (PA)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:HENNEKES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5582 HOFFMAN RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-9717
Mailing Address - Country:US
Mailing Address - Phone:513-575-4236
Mailing Address - Fax:
Practice Address - Street 1:2001 ANDERSON FERRY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3325
Practice Address - Country:US
Practice Address - Phone:513-922-1200
Practice Address - Fax:513-922-2103
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHEPA12241Medicare ID - Type Unspecified
OHS65730Medicare UPIN