Healthcare Provider Details

I. General information

NPI: 1891896726
Provider Name (Legal Business Name): MARY COLLEEN DONNELLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N. HWY 89 NORTHERN ARIZONA VA HCS
PRESCOTT AZ
86313
US

IV. Provider business mailing address

500 N. HWY 89
PRESCOTT AZ
86313
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-4860
  • Fax:
Mailing address:
  • Phone: 928-445-4860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberD42636
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number25942
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: