Provider Demographics
NPI:1700825684
Name:HENNESSY, CAROL A (NP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-747-7396
Practice Address - Street 1:12662 FM 1314 RD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77302-3443
Practice Address - Country:US
Practice Address - Phone:936-524-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y3459OtherBCBSTX
TX8L8790Medicare PIN
TX8L8791Medicare PIN
TX8F6848Medicare PIN
TX8F6784Medicare PIN
TX8Y3459OtherBCBSTX
TX8L8789Medicare PIN