Provider Demographics
NPI:1841405891
Name:DINNAN, KELLY ANN (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DINNAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 DILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-2053
Mailing Address - Country:US
Mailing Address - Phone:406-345-8901
Mailing Address - Fax:
Practice Address - Street 1:107 DILWORTH ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-2053
Practice Address - Country:US
Practice Address - Phone:406-345-8901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI510106908208600000X
MT99170208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1841405891Medicaid