Provider Demographics
NPI:1831304377
Name:HENNING, ALISA (CNM)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:HENNING
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7708 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6510
Mailing Address - Country:US
Mailing Address - Phone:505-924-2229
Mailing Address - Fax:505-554-3673
Practice Address - Street 1:7708 4TH ST NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:505-924-2229
Practice Address - Fax:505-554-3673
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM746367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831304377Medicaid