1124116520 NPI number — MRS. KELLY M HENNESSY OTR/L

Table of content: (NPI 1083920805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124116520 NPI number — MRS. KELLY M HENNESSY OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENNESSY
Provider First Name:
KELLY
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124116520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2620 S UNIVERSITY DR
Provider Second Line Business Mailing Address:
308
Provider Business Mailing Address City Name:
DAVIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33328-1469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-648-5888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16606 SADDLE CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33326-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-660-0551
Provider Business Practice Location Address Fax Number:
954-660-0527
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  OT11129 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z065P . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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