Healthcare Provider Details

I. General information

NPI: 1992969919
Provider Name (Legal Business Name): TERESA R HENNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 BRYANT ST
BUFFALO NY
14222-2006
US

IV. Provider business mailing address

219 BRYANT ST
BUFFALO NY
14222-2006
US

V. Phone/Fax

Practice location:
  • Phone: 716-878-1689
  • Fax: 716-878-1862
Mailing address:
  • Phone: 716-878-1689
  • Fax: 716-878-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number256956
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: