Provider Demographics
NPI:1306993126
Name:HENSON, MICHELE (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:HENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 CANAL STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:912-348-4100
Mailing Address - Fax:
Practice Address - Street 1:143 CANAL STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-348-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115621207K00000X
GA073306207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology