Provider Demographics
NPI:1770879793
Name:DONATHAN, KELLY ANN (DPT, ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DONATHAN
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT, ATC
Mailing Address - Street 1:7815 3RD ST N STE 203
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5443
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:
Practice Address - Street 1:7815 3RD ST N STE 203
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5443
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9844OtherMN BOARD OF PT