Provider Demographics
NPI:1902442429
Name:FELLOWS, DONNA M (LMT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GEMINI PL APT 8
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-9692
Mailing Address - Country:US
Mailing Address - Phone:315-374-0027
Mailing Address - Fax:
Practice Address - Street 1:704 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6035
Practice Address - Country:US
Practice Address - Phone:315-374-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031926225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty