Basic Information
| Provider Information | |||||||||
| NPI: | 1831274828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNENHOEFER | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WENSEL | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9913 N 95TH ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808608998 | ||||||||
| FaxNumber: | 4803779245 | ||||||||
| Practice Location | |||||||||
| Address1: | 9913 N 95TH ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808608998 | ||||||||
| FaxNumber: | 4803779245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5023 | AZ | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 5023 | AZ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3Z3943 | 01 | AZ | HEALTHNET | OTHER | 333821 | 05 | AZ | MEDICAID |