Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 26NJ00760500 | NJ |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 26NJ00760500 | NJ |
NPI | 1215456983 |
---|---|
Provider Name | Amanda Jo Henning |
First Address | Frenchtown, NJ 08825-4022 |
Second Address | Flemington, NJ 08822 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2017 |
Last Update Date | 14/09/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
26NJ00760500 | STATE LICENSE (01) | NJ |