=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174176457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA HENNESSEE FNP, AGACNP, DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2019
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2584 RESERVE ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80516-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-607-9207
-----------------------------------------------------
Fax | 720-738-7873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 479
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80516-0479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-607-9207
-----------------------------------------------------
Fax | 720-738-7873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 0994777
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0994777
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------