Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 35058227M | OH |
NPI | 1003844937 |
---|---|
Provider Name | Jonelle K Mcdonnell |
First Address | Lutz, FL 33558-4880 |
Second Address | Punta Gorda, FL 33950-3903 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2006 |
Last Update Date | 17/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
145A6 | BCBS PERSONAL PROVIDER NUMBER (01) | FL |
G66716 | (02) | OH |
ME104122 | MEDICAL LICENSE FLORIDA (01) | FL |