Provider Demographics
NPI:1912393539
Name:HENNELLY, MARIE OLIVA (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:OLIVA
Last Name:HENNELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412-22 FAIRMOUNT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-684-5344
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:401-55 W ALLEGHENY AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3644
Practice Address - Country:US
Practice Address - Phone:215-291-2500
Practice Address - Fax:215-291-2502
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60748517207Q00000X
PAMD465402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program