Provider Demographics
NPI:1760414338
Name:HENNING, MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HENNING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 CITY CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-8960
Mailing Address - Country:US
Mailing Address - Phone:252-338-2155
Mailing Address - Fax:252-338-7704
Practice Address - Street 1:1735 CITY CENTER BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8960
Practice Address - Country:US
Practice Address - Phone:252-338-2155
Practice Address - Fax:252-338-7704
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00404207R00000X, 208000000X, 2080B0002X
VA0102205392207R00000X, 2080B0002X, 208000000X
PAOS013453207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2080B0002XAllopathic & Osteopathic PhysiciansPediatricsObesity Medicine