Healthcare Provider Details

I. General information

NPI: 1174176457
Provider Name (Legal Business Name): ALICIA HENNESSEE FNP, AGACNP, DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2584 RESERVE ST
ERIE CO
80516-2505
US

IV. Provider business mailing address

PO BOX 479
ERIE CO
80516-0479
US

V. Phone/Fax

Practice location:
  • Phone: 720-607-9207
  • Fax: 720-738-7873
Mailing address:
  • Phone: 720-607-9207
  • Fax: 720-738-7873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0994777
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0994777
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: