Provider Demographics
NPI:1801465778
Name:DONNELLY, JAMIE LYNN
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
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 1:1955 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-9630
Mailing Address - Country:US
Mailing Address - Phone:608-963-9163
Mailing Address - Fax:
Practice Address - Street 1:1955 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9630
Practice Address - Country:US
Practice Address - Phone:608-963-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI155479-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse