Provider Demographics
NPI:1407227101
Name:HENNESSY, CARLEY
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:
Other - Last Name:BUTTELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1700 11TH ST W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4500
Mailing Address - Country:US
Mailing Address - Phone:701-774-7687
Mailing Address - Fax:
Practice Address - Street 1:1700 11TH ST W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4500
Practice Address - Country:US
Practice Address - Phone:701-774-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0617363A00000X
MTMED-PAC-LIC-76234363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant