Provider Demographics
NPI:1265716773
Name:HENNESSEY, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WATER OAK PL
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-246-4103
Mailing Address - Fax:
Practice Address - Street 1:1109 PALM COAST PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-445-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist