Provider Demographics
NPI:1083761639
Name:HENNESSY, DONNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 ARMSTRONG AVE
Mailing Address - Street 2:APARTMENT #A-1
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2358
Mailing Address - Country:US
Mailing Address - Phone:718-948-7771
Mailing Address - Fax:
Practice Address - Street 1:562 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-562-3776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant