Provider Demographics
NPI:1528076940
Name:HENNIGAN, STEPHANIE LYNN (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:HENNIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 HORIZON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7805
Mailing Address - Country:US
Mailing Address - Phone:972-664-0644
Mailing Address - Fax:972-664-0301
Practice Address - Street 1:3140 HORIZON RD STE 101
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7805
Practice Address - Country:US
Practice Address - Phone:972-664-0644
Practice Address - Fax:972-664-0301
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96157207RR0500X
TXM9353207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX194516401Medicaid
TX194516406Medicaid
TX194516402Medicaid
TXTXB121647Medicare PIN
TXTXB121648Medicare PIN
TX8K8458Medicare PIN
TX194516401Medicaid
TX194516402Medicaid