Provider Demographics
NPI:1104879592
Name:HENNE, AMY RENEE (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RENEE
Last Name:HENNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RENEE
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:
Practice Address - Street 1:7782 20TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8524
Practice Address - Country:US
Practice Address - Phone:616-685-8700
Practice Address - Fax:616-457-5567
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4311439Medicaid
MI4320797Medicaid
MI4308021Medicaid
MI4877231Medicaid
MI4311439Medicaid
MIH38873Medicare UPIN
MIM02830102Medicare ID - Type Unspecified
MI4320797Medicaid