Provider Demographics
NPI:1538699384
Name:HENNIGAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HENNIGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9504
Mailing Address - Country:US
Mailing Address - Phone:570-586-2011
Mailing Address - Fax:
Practice Address - Street 1:1451 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9504
Practice Address - Country:US
Practice Address - Phone:570-586-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017524363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health