Provider Demographics
NPI:1215988852
Name:HENNEBERRY, MICHELLE D (PMHNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:HENNEBERRY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 STATE ST
Mailing Address - Street 2:SUITE 23
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5435
Mailing Address - Country:US
Mailing Address - Phone:207-945-3615
Mailing Address - Fax:207-945-3444
Practice Address - Street 1:263 STATE ST
Practice Address - Street 2:SUITE 23
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5435
Practice Address - Country:US
Practice Address - Phone:207-945-3615
Practice Address - Fax:207-945-3444
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER037051363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME255830000Medicaid
ME048586OtherANTHEM
MENP3816Medicare ID - Type Unspecified
ME255830000Medicaid