Healthcare Provider Details

I. General information

NPI: 1699826693
Provider Name (Legal Business Name): THERESA ANN HENNESSEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/07/2023
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SHRINERS HOSPITALS FOR CHILDREN FAIRFAX ROAD AT VIRGINIA STREET
SALT LAKE CITY UT
84103-4399
US

IV. Provider business mailing address

SHRINERS HOSPITALS FOR CHILDREN SALT DEPT 5034
LOS ANGELES CA
90084-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-536-3600
  • Fax: 801-536-3868
Mailing address:
  • Phone: 813-281-8478
  • Fax: 813-281-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number5897436-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: