Provider Demographics
NPI:1952634545
Name:DONNELLY, SHAYLA
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5670 165TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KINDRED
Mailing Address - State:ND
Mailing Address - Zip Code:58051-9540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist