Provider Demographics
NPI:1740059880
Name:HENNING, BROOKE KALEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:KALEIGH
Last Name:HENNING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 S BLISSFIELD HWY
Mailing Address - Street 2:
Mailing Address - City:BLISSFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49228-9550
Mailing Address - Country:US
Mailing Address - Phone:517-486-1044
Mailing Address - Fax:
Practice Address - Street 1:770 RIVERSIDE AVE STE 105
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1465
Practice Address - Country:US
Practice Address - Phone:517-265-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant