Provider Demographics
NPI:1386326148
Name:DONNELLY, EMMA THERESE
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:THERESE
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 1:201 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-3248
Mailing Address - Country:US
Mailing Address - Phone:585-747-1215
Mailing Address - Fax:
Practice Address - Street 1:725 IRVING AVE STE 804
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1612
Practice Address - Country:US
Practice Address - Phone:315-214-7700
Practice Address - Fax:315-214-7701
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF383558-01363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics