Provider Demographics
NPI:1033769468
Name:DONAHUE, COLLEEN GRACE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:GRACE
Last Name:DONAHUE
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 1:306 E WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2557
Mailing Address - Country:US
Mailing Address - Phone:847-226-7412
Mailing Address - Fax:
Practice Address - Street 1:306 E WAVERLY RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-2557
Practice Address - Country:US
Practice Address - Phone:847-226-7412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant