Provider Demographics
NPI:1851119473
Name:DONNELLY, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
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 1:22 STURGIS RD
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824-1231
Mailing Address - Country:US
Mailing Address - Phone:732-395-9707
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:22 STURGIS RD
Practice Address - Street 2:
Practice Address - City:KENDALL PARK
Practice Address - State:NJ
Practice Address - Zip Code:08824-1231
Practice Address - Country:US
Practice Address - Phone:732-395-9707
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033347363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty