Provider Demographics
NPI:1265058697
Name:HENNIGAN, GRETCHEN SUE (FNP)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:SUE
Last Name:HENNIGAN
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 1:231 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1440
Mailing Address - Country:US
Mailing Address - Phone:304-672-3431
Mailing Address - Fax:
Practice Address - Street 1:231 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1440
Practice Address - Country:US
Practice Address - Phone:304-672-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily