Provider Demographics
NPI:1184663767
Name:O'DONOGHUE, CAROL CAMPBELL (CNM)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:CAMPBELL
Last Name:O'DONOGHUE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2502
Mailing Address - Country:US
Mailing Address - Phone:610-525-6090
Mailing Address - Fax:610-525-6631
Practice Address - Street 1:918 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2502
Practice Address - Country:US
Practice Address - Phone:610-525-6090
Practice Address - Fax:610-525-6631
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010091367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015763080001Medicaid