Provider Demographics
NPI:1447470372
Name:HENEGAN, JULIE A (LCCE)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:HENEGAN
Suffix:
Gender:F
Credentials:LCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12553
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-2553
Mailing Address - Country:US
Mailing Address - Phone:360-754-8080
Mailing Address - Fax:
Practice Address - Street 1:10922 GENTRY CT SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-9396
Practice Address - Country:US
Practice Address - Phone:360-754-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAST00001509246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7408198Medicaid