Provider Demographics
NPI:1215186069
Name:MCDONNELL, PEGGY ANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ANNE
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:ANNE
Other - Last Name:STATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2128 ELMWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1910
Mailing Address - Country:US
Mailing Address - Phone:716-824-4500
Mailing Address - Fax:716-874-3195
Practice Address - Street 1:2128 ELMWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1910
Practice Address - Country:US
Practice Address - Phone:716-824-4500
Practice Address - Fax:716-874-3195
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP66979225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant