Provider Demographics
NPI:1275587917
Name:DORNAN, KIMBERLY E (MACOM, LAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:E
Last Name:DORNAN
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 NE 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4510
Mailing Address - Country:US
Mailing Address - Phone:503-771-7441
Mailing Address - Fax:503-282-9899
Practice Address - Street 1:3024 NE 63RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4510
Practice Address - Country:US
Practice Address - Phone:503-771-7441
Practice Address - Fax:503-287-9899
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00534171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist