Provider Demographics
NPI:1598318966
Name:DONNELLY, SALLY CATHERINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:CATHERINE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:NP
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1200 E MAIN ST STE 12
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1738
Practice Address - Country:US
Practice Address - Phone:864-560-9260
Practice Address - Fax:864-560-9265
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC216119363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6239Medicaid
SCSCG2815019OtherMEDICARE PIN
SCSCG281J577OtherMEDICARE PIN
SCSCG2816121OtherMEDICARE PIN
SCSCG2816084OtherMEDICARE PIN
SCSCG2816067OtherMEDICARE PIN