Provider Demographics
NPI:1346561925
Name:DONNELLY, MELISSA SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:S
Other - Last Name:ZIKMUND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4242 FARNAM ST
Practice Address - Street 2:#650
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2806
Practice Address - Country:US
Practice Address - Phone:402-559-8600
Practice Address - Fax:402-559-5010
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47081304012OtherNEBRASKA MEDICAID