Provider Demographics
NPI:1295233997
Name:DALY, JENNELLE LYNNE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNELLE
Middle Name:LYNNE
Last Name:DALY
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 1:4842 E EMILE ZOLA AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-3518
Mailing Address - Country:US
Mailing Address - Phone:561-672-9209
Mailing Address - Fax:
Practice Address - Street 1:9300 E RAINTREE DR STE 130
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-7313
Practice Address - Country:US
Practice Address - Phone:602-677-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7105208VP0014X, 363AM0700X, 2081S0010X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty