=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609965052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAUREEN CECILIA DONNELLY II PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 10/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CORNER OF ROUTE N12 AND N7
-----------------------------------------------------
City | FORT DEFIANCE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86504-0649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-729-8810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 649
-----------------------------------------------------
City | FORT DEFIANCE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86504-0649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-929-8810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 3049
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 1780630491
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | NM
-----------------------------------------------------
Identifier Issuer | GROUP NPI #
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 1780630491
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | NM
-----------------------------------------------------
Identifier Issuer | GROUP NPI #
-----------------------------------------------------