Provider Demographics
NPI:1053960609
Name:DONNELLY, BRANDI
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-1623
Mailing Address - Country:US
Mailing Address - Phone:563-210-1546
Mailing Address - Fax:
Practice Address - Street 1:4500 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1626
Practice Address - Country:US
Practice Address - Phone:563-742-3201
Practice Address - Fax:563-742-3205
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA155880363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care