Provider Demographics
NPI:1114446515
Name:AVERY, DONNA MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:AVERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746096
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6096
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:
Practice Address - Street 1:2420 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-2321
Practice Address - Country:US
Practice Address - Phone:618-318-8809
Practice Address - Fax:618-615-4205
Is Sole Proprietor?:No
Enumeration Date:2017-09-17
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily