Provider Demographics
NPI:1699213132
Name:LENNEVILLE, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LENNEVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4076 NEELY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:907-361-4835
Mailing Address - Fax:
Practice Address - Street 1:1431 NURSERY ST STE 102
Practice Address - Street 2:
Practice Address - City:FOGELSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18051-1612
Practice Address - Country:US
Practice Address - Phone:610-821-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE31247208000000X
390200000X
PAMD483842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program