Provider Demographics
NPI:1629204284
Name:DONNELLY, STACY ANN (DO)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANN
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6644
Mailing Address - Fax:270-858-4027
Practice Address - Street 1:2680 CAMPBELLSVILLE RD
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-8898
Practice Address - Country:US
Practice Address - Phone:270-299-2111
Practice Address - Fax:270-299-2211
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100427790Medicaid
KYK207140Medicare PIN