Provider Demographics
NPI:1235904236
Name:DONNELLAN, BROOKE MACKENZIE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MACKENZIE
Last Name:DONNELLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 HUNTS BROOK RD
Mailing Address - Street 2:
Mailing Address - City:QUAKER HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06375-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4292
Practice Address - Country:US
Practice Address - Phone:203-576-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant