Provider Demographics
NPI:1245408855
Name:HOMANN, DONNA R
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:HOMANN
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 1:3012 DEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-2356
Mailing Address - Country:US
Mailing Address - Phone:217-235-0011
Mailing Address - Fax:217-235-0036
Practice Address - Street 1:3012 DEWITT AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-2356
Practice Address - Country:US
Practice Address - Phone:217-235-0011
Practice Address - Fax:217-235-0036
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4046890001Medicare NSC