1629204284 NPI number — DR. STACY ANN DONNELLY D.O

Table of content: DR. STACY ANN DONNELLY D.O (NPI 1629204284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629204284 NPI number — DR. STACY ANN DONNELLY D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONNELLY
Provider First Name:
STACY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629204284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1080
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURKESVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42717-1080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-858-6644
Provider Business Mailing Address Fax Number:
270-858-4027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2680 CAMPBELLSVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42743-8898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-299-2111
Provider Business Practice Location Address Fax Number:
270-299-2211
Provider Enumeration Date:
06/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  04015 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100427790 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com