Provider Demographics
NPI:1053398909
Name:HENNEBERRY, CATHIE SUE (FNP, APRN-BC, MSN)
Entity type:Individual
Prefix:MRS
First Name:CATHIE
Middle Name:SUE
Last Name:HENNEBERRY
Suffix:
Gender:F
Credentials:FNP, APRN-BC, MSN
Other - Prefix:MRS
Other - First Name:CATHIE
Other - Middle Name:SUE
Other - Last Name:GWIN-HENNEBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1213 15TH AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3800
Mailing Address - Country:US
Mailing Address - Phone:701-572-7651
Mailing Address - Fax:
Practice Address - Street 1:1213 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801
Practice Address - Country:US
Practice Address - Phone:701-572-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN26836363LF0000X
NDR36163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1476052Medicaid
MTP58916Medicare UPIN
MT4308369Medicaid