Provider Demographics
NPI:1588876916
Name:COLLEEN HENNELLY, O.D.
Entity type:Organization
Organization Name:COLLEEN HENNELLY, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:HENNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-350-1085
Mailing Address - Street 1:3601 PAGE DR
Mailing Address - Street 2:# 4
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-4034
Mailing Address - Country:US
Mailing Address - Phone:773-350-1085
Mailing Address - Fax:
Practice Address - Street 1:3601 PAGE DR
Practice Address - Street 2:# 4
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-4034
Practice Address - Country:US
Practice Address - Phone:773-350-1085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3237152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty