Provider Demographics
NPI:1417961731
Name:HENNESSEE, ARETHA A (CERTIFIED REGISTERED)
Entity Type:Individual
Prefix:MS
First Name:ARETHA
Middle Name:A
Last Name:HENNESSEE
Suffix:
Gender:F
Credentials:CERTIFIED REGISTERED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E. 33RD STREET
Mailing Address - Street 2:SUITE 551
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-554-4511
Mailing Address - Fax:410-554-6490
Practice Address - Street 1:200 E. 33RD STREET
Practice Address - Street 2:SUITE 551
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-554-4511
Practice Address - Fax:410-554-6490
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR138505163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ66372Medicare UPIN