Provider Demographics
NPI:1609838036
Name:DONELSON, MARK ALAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:DONELSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 STULL DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:573-331-5028
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:C/O SAINT FRANCIS REHAB
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4910
Practice Address - Country:US
Practice Address - Phone:573-331-5153
Practice Address - Fax:573-331-5028
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1139082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer