Provider Demographics
NPI:1902133978
Name:DONNELLY, MARK (LAC, MS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:LAC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CIRCLE LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-2703
Mailing Address - Country:US
Mailing Address - Phone:516-735-1699
Mailing Address - Fax:516-249-8514
Practice Address - Street 1:177 CONKLIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2501
Practice Address - Country:US
Practice Address - Phone:516-249-3236
Practice Address - Fax:516-249-8514
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001633-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist