Healthcare Provider Details

I. General information

NPI: 1912814492
Provider Name (Legal Business Name): NICOLE DONNELLY MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 LEJOK ST
ELLSWORTH ME
04605-4767
US

IV. Provider business mailing address

36 CENTURY ST
BREWER ME
04412-2432
US

V. Phone/Fax

Practice location:
  • Phone: 207-667-4722
  • Fax:
Mailing address:
  • Phone: 931-302-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP3411
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: