1366637712 NPI number — SARA KATHERINE HENNESSY OTR/L

Table of content: SARA KATHERINE HENNESSY OTR/L (NPI 1366637712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366637712 NPI number — SARA KATHERINE HENNESSY OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENNESSY
Provider First Name:
SARA
Provider Middle Name:
KATHERINE
Provider Name Prefix Text:
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:
1366637712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2213 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50312-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-237-3974
Provider Business Mailing Address Fax Number:
515-288-0122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 N FREDERICK AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
OELWEIN
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50662-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-283-2002
Provider Business Practice Location Address Fax Number:
319-283-2015
Provider Enumeration Date:
09/10/2007

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: 225X00000X , with the licence number:  01030 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1821461344 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64080680 . This is a "AMERIHEALTH CARITAS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1821461344 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 35202809 . This is a "AMERIGROUP" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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