Provider Demographics
NPI:1174176457
Name:HENNESSEE, ALICIA (FNP, AGACNP, DNP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:HENNESSEE
Suffix:
Gender:F
Credentials:FNP, AGACNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-0479
Mailing Address - Country:US
Mailing Address - Phone:720-607-9207
Mailing Address - Fax:720-738-7873
Practice Address - Street 1:2584 RESERVE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-2505
Practice Address - Country:US
Practice Address - Phone:720-607-9207
Practice Address - Fax:720-738-7873
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0994777363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000178345Medicaid