Provider Demographics
NPI:1144773383
Name:DONNELLY, STEPHEN MICHAEL (CRNP)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:814-934-3750
Mailing Address - Fax:
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-214-3943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-24
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN602929163WX0200X
PASP016592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0200XNursing Service ProvidersRegistered NurseOncology