Provider Demographics
NPI:1720028699
Name:HENNESSY, THERESE A (DO)
Entity Type:Individual
Prefix:DR
First Name:THERESE
Middle Name:A
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 S 30TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:402-991-5642
Practice Address - Street 1:4920 S 30TH ST
Practice Address - Street 2:STE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-991-5642
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE238208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H09835Medicare UPIN
281807Medicare ID - Type Unspecified
NE47054899017Medicaid