Provider Demographics
NPI:1629377627
Name:DONNELLY, KRISTY (DC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 DEER CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3833
Mailing Address - Country:US
Mailing Address - Phone:724-787-7469
Mailing Address - Fax:
Practice Address - Street 1:6947 MERRILL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2684
Practice Address - Country:US
Practice Address - Phone:904-743-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor