Basic Information
| Provider Information | |||||||||
| NPI: | 1699826693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNESSEY | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | SHRINERS HOSPITALS FOR CHILDREN SALT | ||||||||
| Address2: | DEPT 5034 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900840001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818478 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
| Address2: | FAIRFAX ROAD AT VIRGINIA STREET | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841034399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015363600 | ||||||||
| FaxNumber: | 8015363868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | 5897436-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5897436-8905 | 01 | UT | CONTROLLED SUBSTANCE LIC | OTHER | 5897436-1205 | 01 | UT | STATE LICENSE | OTHER | BH9108273 | 01 | UT | DEA LICENSE | OTHER |