Provider Demographics
NPI:1518015247
Name:HENNESSEE, PHEDRA ELIZABETH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:PHEDRA
Middle Name:ELIZABETH
Last Name:HENNESSEE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W WENDOVER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-8438
Mailing Address - Country:US
Mailing Address - Phone:336-274-6515
Mailing Address - Fax:336-691-8042
Practice Address - Street 1:1210 NEW GARDEN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2721
Practice Address - Country:US
Practice Address - Phone:336-852-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02997363A00000X
ALPA589363AM0700X
FLPA9103760363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102287Medicaid
NCP01031818OtherRR MEDICARE
NC8102287Medicaid