Provider Demographics
NPI:1740787423
Name:DONNELLY, THERESE A (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:A
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5009
Mailing Address - Country:US
Mailing Address - Phone:610-955-5338
Mailing Address - Fax:
Practice Address - Street 1:325 CENTRAL AVE STE 200
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3265
Practice Address - Country:US
Practice Address - Phone:610-644-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059740363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical