Provider Demographics
NPI:1326142886
Name:VINNEDGE, DONNA LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LOUISE
Last Name:VINNEDGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 2ND ST. S. SUITE 2
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4406
Mailing Address - Country:US
Mailing Address - Phone:406-770-3171
Mailing Address - Fax:406-770-3173
Practice Address - Street 1:914 13TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4406
Practice Address - Country:US
Practice Address - Phone:406-770-3171
Practice Address - Fax:406-770-3173
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3400228Medicaid
MT3400228Medicaid