Provider Demographics
NPI:1831428317
Name:HENNESSY, GINA MICHELLE (APRN)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MICHELLE
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:MASCHERINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:702 GORDON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1253
Mailing Address - Country:US
Mailing Address - Phone:610-363-1330
Mailing Address - Fax:610-524-8574
Practice Address - Street 1:702 GORDON DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1253
Practice Address - Country:US
Practice Address - Phone:610-363-1330
Practice Address - Fax:610-524-8574
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010586208000000X, 363L00000X, 363LP2300X
DELJ-0000276363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026832780001Medicaid