Healthcare Provider Details

I. General information

NPI: 1770915431
Provider Name (Legal Business Name): NICOLE DONNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 09/03/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 N WHITTAKER ST STE 204
NEW BUFFALO MI
49117-1173
US

IV. Provider business mailing address

300 W MICHIGAN ST
NEW BUFFALO MI
49117-1370
US

V. Phone/Fax

Practice location:
  • Phone: 269-235-9821
  • Fax: 269-359-3735
Mailing address:
  • Phone: 708-921-5381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.002629
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22006997A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101006661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: