Provider Demographics
NPI:1699826693
Name:HENNESSEY, THERESA ANN (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:SHRINERS HOSPITALS FOR CHILDREN SALT
Mailing Address - Street 2:DEPT 5034
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-0001
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:SHRINERS HOSPITALS FOR CHILDREN
Practice Address - Street 2:FAIRFAX ROAD AT VIRGINIA STREET
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-4399
Practice Address - Country:US
Practice Address - Phone:801-536-3600
Practice Address - Fax:801-536-3868
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT5897436-1205207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5897436-8905OtherCONTROLLED SUBSTANCE LIC
UT5897436-1205OtherSTATE LICENSE
UTBH9108273OtherDEA LICENSE