Provider Demographics
NPI:1053304386
Name:DONOVAN, KATHRYN MARIE (DC)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:MARIE
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4961 RICE LAKE RD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-8438
Mailing Address - Country:US
Mailing Address - Phone:218-391-9976
Mailing Address - Fax:
Practice Address - Street 1:4961 RICE LAKE RD
Practice Address - Street 2:SUITE #103
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-8438
Practice Address - Country:US
Practice Address - Phone:218-391-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2157492OtherFIRST HEALTH
MN558525200Medicaid
MN231905OtherCHIROCARE
MN62G00DOOtherBLUE CROSS BLUE SHIELD
MN558525200Medicaid
MN2157492OtherFIRST HEALTH
MN350002664Medicare ID - Type Unspecified