Provider Demographics
NPI:1073280582
Name:HENNESSY, MAGDALENA
Entity Type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LAMA DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3327
Mailing Address - Country:US
Mailing Address - Phone:631-804-8069
Mailing Address - Fax:
Practice Address - Street 1:33 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11959-4000
Practice Address - Country:US
Practice Address - Phone:631-653-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310386363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health