Provider Demographics
NPI:1629829957
Name:HENNINGER, COURTNEY ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELIZABETH
Last Name:HENNINGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MILL ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1640
Mailing Address - Country:US
Mailing Address - Phone:315-719-7974
Mailing Address - Fax:
Practice Address - Street 1:1455 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2006
Practice Address - Country:US
Practice Address - Phone:585-922-2575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine