Provider Demographics
NPI:1124116520
Name:HENNESSY, KELLY M (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 S UNIVERSITY DR
Mailing Address - Street 2:308
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1469
Mailing Address - Country:US
Mailing Address - Phone:954-648-5888
Mailing Address - Fax:
Practice Address - Street 1:16606 SADDLE CLUB RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-1808
Practice Address - Country:US
Practice Address - Phone:954-660-0551
Practice Address - Fax:954-660-0527
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ065POtherBLUE CROSS BLUE SHIELD