Provider Demographics
NPI:1124696174
Name:DONNELLY, LAURA JANE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JANE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 PARKERS LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3209
Mailing Address - Country:US
Mailing Address - Phone:703-664-7000
Mailing Address - Fax:703-664-7666
Practice Address - Street 1:2501 PARKERS LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3209
Practice Address - Country:US
Practice Address - Phone:703-664-7000
Practice Address - Fax:703-664-7666
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant