Provider Demographics
NPI:1205057015
Name:HENNESSY, PATRICIA JANE (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JANE
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:P
Other - Middle Name:J
Other - Last Name:HENNESSY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0913
Mailing Address - Country:US
Mailing Address - Phone:208-265-9909
Mailing Address - Fax:208-265-5351
Practice Address - Street 1:1205 HIGHWAY 2
Practice Address - Street 2:SUITE 301
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-0913
Practice Address - Country:US
Practice Address - Phone:208-265-9909
Practice Address - Fax:208-265-5351
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4085207Q00000X
ID7962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D96164Medicare UPIN