Provider Demographics
NPI:1073665543
Name:DONNELLY, NICOLE (MPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 FERNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19001-3002
Mailing Address - Country:US
Mailing Address - Phone:215-887-5859
Mailing Address - Fax:
Practice Address - Street 1:1111 STREET RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-4250
Practice Address - Country:US
Practice Address - Phone:215-675-4466
Practice Address - Fax:215-675-3711
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1639871Medicare UPIN