Provider Demographics
NPI:1538574090
Name:HENLINE, CARLYE J (PA)
Entity type:Individual
Prefix:
First Name:CARLYE
Middle Name:J
Last Name:HENLINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLYE
Other - Middle Name:
Other - Last Name:YAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 6TH AVE
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8358
Practice Address - Country:US
Practice Address - Phone:269-273-9782
Practice Address - Fax:269-273-9711
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1538574090Medicaid