Healthcare Provider Details

I. General information

NPI: 1417961731
Provider Name (Legal Business Name): ARETHA A. HENNESSEE CERTIFIED REGISTERED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E. 33RD STREET SUITE 551
BALTIMORE MD
21218
US

IV. Provider business mailing address

200 E. 33RD STREET SUITE 551
BALTIMORE MD
21218
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-4511
  • Fax: 410-554-6490
Mailing address:
  • Phone: 410-554-4511
  • Fax: 410-554-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR138505
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR138505
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: