Provider Demographics
NPI:1154686301
Name:HENNESSY, TUESDAY NICOLE (OD)
Entity Type:Individual
Prefix:MRS
First Name:TUESDAY
Middle Name:NICOLE
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:TUESDAY
Other - Middle Name:NICOLE
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4804 N CHAMBERS
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239
Mailing Address - Country:US
Mailing Address - Phone:303-576-6655
Mailing Address - Fax:303-576-8131
Practice Address - Street 1:4804 N CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239
Practice Address - Country:US
Practice Address - Phone:303-576-6655
Practice Address - Fax:303-576-8131
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002923152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51428717Medicaid
CO51428717Medicaid