Basic Information
| Provider Information | |||||||||
| NPI: | 1912393539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNELLY | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | OLIVA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412-22 FAIRMOUNT AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191302908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156845344 | ||||||||
| FaxNumber: | 2152324093 | ||||||||
| Practice Location | |||||||||
| Address1: | 401-55 W ALLEGHENY AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191333644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152912500 | ||||||||
| FaxNumber: | 2152912502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD60748517 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD465402 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.