Provider Demographics
NPI:1437151412
Name:DONOVAN, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570-2006
Mailing Address - Country:US
Mailing Address - Phone:603-752-2040
Mailing Address - Fax:603-752-7797
Practice Address - Street 1:2 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:NH
Practice Address - Zip Code:03581-1502
Practice Address - Country:US
Practice Address - Phone:603-752-2040
Practice Address - Fax:603-752-7797
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0210072303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH23YP02556NH02OtherANTHEM BC/BS
NH3072649Medicaid
NH9680107001OtherCIGNA HEALTHCARE
020350051OtherFEDERAL TAX ID
NH30342708Medicaid
5830418OtherAETNA GROUP
NH0210072303OtherSTATE LICENSE #
NH0210072303OtherSTATE LICENSE #
5830418OtherAETNA GROUP
NH9680107001OtherCIGNA HEALTHCARE