Provider Demographics
NPI:1336354117
Name:HENLEY, ANITA HAWKS (DO)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:HAWKS
Last Name:HENLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:BESS
Other - Last Name:HAWKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:590 RADIO HILL RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4224
Mailing Address - Country:US
Mailing Address - Phone:276-783-8183
Mailing Address - Fax:276-378-0218
Practice Address - Street 1:590 RADIO HILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4224
Practice Address - Country:US
Practice Address - Phone:276-783-8183
Practice Address - Fax:276-378-0218
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202185208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336354117Medicaid