Provider Demographics
NPI:1558065748
Name:DONNER, MEMORY LEIGH (PEER SPECIALIST)
Entity Type:Individual
Prefix:MS
First Name:MEMORY
Middle Name:LEIGH
Last Name:DONNER
Suffix:
Gender:F
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 OAK ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-3111
Mailing Address - Country:US
Mailing Address - Phone:631-257-5173
Mailing Address - Fax:
Practice Address - Street 1:445 OAK ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-3111
Practice Address - Country:US
Practice Address - Phone:631-257-5173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist