Provider Demographics
NPI:1205821824
Name:HENNESY, STACEY LORRAINE (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LORRAINE
Last Name:HENNESY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911057
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1057
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6640
Practice Address - Street 1:14300 ORCHARD PKWY
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80023-9206
Practice Address - Country:US
Practice Address - Phone:303-426-2580
Practice Address - Fax:303-426-2590
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35332207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01353325Medicaid
CO01353325Medicaid