Provider Demographics
NPI:1841274248
Name:HENNEQUIN, KARLA MAY (PAC)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:MAY
Last Name:HENNEQUIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SW 7TH ST STE A205
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2983
Mailing Address - Country:US
Mailing Address - Phone:877-522-1275
Mailing Address - Fax:833-888-7145
Practice Address - Street 1:3345 39TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7539
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
A2437OtherMEDCOST
7392724OtherAETNA
7392724OtherAETNA