Provider Demographics
NPI:1063725547
Name:DONNELLY, JENNIFER L (DFNP, APRN, NP-BC)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:DFNP, APRN, NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-9003
Mailing Address - Country:US
Mailing Address - Phone:580-458-2373
Mailing Address - Fax:
Practice Address - Street 1:602 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6912
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK81703363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid