Provider Demographics
NPI:1356495907
Name:KENTLEY, DONNA M (PA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:KENTLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:508-764-2432
Practice Address - Street 1:55 SAYLES ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-1729
Practice Address - Country:US
Practice Address - Phone:508-764-2400
Practice Address - Fax:508-909-7770
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003868363A00000X
MAPA5624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8357527Medicaid
WA8357527Medicaid
WA8851982Medicare PIN
WAP25448Medicare UPIN
WAGAB19687Medicare PIN
WA8851983Medicare PIN
WA8851985Medicare PIN
WAG8872404Medicare PIN