Basic Information
| Provider Information | |||||||||
| NPI: | 1215456983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNING | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | MSN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 BARBERTOWN IDELL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCHTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088099130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 WESTCOTT DR | ||||||||
| Address2: | |||||||||
| City: | FLEMINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9087886535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 09/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 26NJ00760500 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QA0505X | 26NJ00760500 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26NJ00760500 | 01 | NJ | STATE LICENSE | OTHER |