1316486285 NPI number — MRS. KELLI M DONOVAN PA

Table of content: MRS. KELLI M DONOVAN PA (NPI 1316486285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316486285 NPI number — MRS. KELLI M DONOVAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONOVAN
Provider First Name:
KELLI
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANOW
Provider Other First Name:
KELLI
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316486285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 SEAGATE
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-1558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
567-585-1945
Provider Business Mailing Address Fax Number:
419-824-7359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2109 HUGHES DR STE 450
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-2003
Provider Business Practice Location Address Fax Number:
419-479-6977
Provider Enumeration Date:
02/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  50005003RX , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0214875 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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