Provider Demographics
NPI:1528028677
Name:KING, DONELLE LYNN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:DONELLE
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:DONELLE
Other - Middle Name:LYNN
Other - Last Name:GRAMSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-587-4800
Practice Address - Fax:763-587-4885
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR172511-9363LF0000X
IA0384015-22363LF0000X
MN1942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0424440Medicaid
IA0424440Medicaid
IAQ05003Medicare UPIN