Provider Demographics
NPI:1669504957
Name:HENNESSEY, MELISSA CAMILLE (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CAMILLE
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:CAMILLE
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:6060 PIEDMONT ROW DR S FL 8
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28287-3891
Practice Address - Country:US
Practice Address - Phone:704-489-3094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYIP889207R00000X
NC2007-00959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0095AMedicaid
NC1669504957Medicaid
NC5907474Medicaid
NC1669504957Medicaid
SCN0095AMedicaid