Provider Demographics
NPI:1871553933
Name:HENNELLY, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HENNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:JEMEZ PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87024-0279
Mailing Address - Country:US
Mailing Address - Phone:575-834-7413
Mailing Address - Fax:575-834-7517
Practice Address - Street 1:110 SHEEP SPRINGS
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024-0279
Practice Address - Country:US
Practice Address - Phone:575-834-7413
Practice Address - Fax:575-834-7517
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM75-167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMC97828Medicare UPIN