Healthcare Provider Details

I. General information

NPI: 1346870805
Provider Name (Legal Business Name): MORGEN ELIZABETH HENNESSY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4570
  • Fax:
Mailing address:
  • Phone: 802-847-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0031448
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: