Provider Demographics
NPI:1417712571
Name:DECOTEAU, DONOVAN JAMES
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:JAMES
Last Name:DECOTEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-3223
Mailing Address - Country:US
Mailing Address - Phone:701-739-2862
Mailing Address - Fax:
Practice Address - Street 1:723 N 4TH ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-3223
Practice Address - Country:US
Practice Address - Phone:701-739-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker