Provider Demographics
NPI:1588231328
Name:HENAGER, GREGG
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:HENAGER
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 1:1244 VAIL ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-9513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 VAIL ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-9513
Practice Address - Country:US
Practice Address - Phone:812-385-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28210519A364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care