Basic Information
Provider Information | |||||||||
NPI: | 1003279209 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENKEL | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | GRACE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUTH | ||||||||
OtherFirstName: | ANDREA | ||||||||
OtherMiddleName: | GRACE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3850 TUNLAW RD NW | ||||||||
Address2: | APT 507 | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200074806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514024324 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 PASTEUR DR | ||||||||
Address2: | RM. G333 | ||||||||
City: | STANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 943052200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6504987570 | ||||||||
FaxNumber: | 6507237737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2016 | ||||||||
LastUpdateDate: | 07/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A151537 | CA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.