Provider Demographics
NPI:1861806861
Name:O'DONNELL, HARLA KELLY (DO)
Entity type:Individual
Prefix:
First Name:HARLA
Middle Name:KELLY
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 TANYARD ROAD, SUITE A100
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-1016
Mailing Address - Country:US
Mailing Address - Phone:856-566-7010
Mailing Address - Fax:856-566-6961
Practice Address - Street 1:1600 HADDON AVE RM 122
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3872
Practice Address - Fax:856-365-4010
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10412100208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1P9364OtherMEDICARE PIN