Provider Demographics
NPI:1255063699
Name:DONNELLY, JANE GRACE (APRN)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:GRACE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-7573
Mailing Address - Country:US
Mailing Address - Phone:203-610-1823
Mailing Address - Fax:
Practice Address - Street 1:401 MONROE TPKE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2276
Practice Address - Country:US
Practice Address - Phone:203-452-1063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics