Basic Information
| Provider Information | |||||||||
| NPI: | 1487656815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONNELLY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037766652 | ||||||||
| FaxNumber: | 7037766078 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037766652 | ||||||||
| FaxNumber: | 7037766078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 218196 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 0101240417 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02110034 | 05 | NY | MEDICAID |