Provider Demographics
NPI:1740950054
Name:DONNELLY, KEVIN (CRNP-FNP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:CRNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 OLDE DUTCH DR
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:DE
Mailing Address - Zip Code:19734-2209
Mailing Address - Country:US
Mailing Address - Phone:302-465-7998
Mailing Address - Fax:
Practice Address - Street 1:501 S UNION AVE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3409
Practice Address - Country:US
Practice Address - Phone:443-843-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily