Healthcare Provider Details

I. General information

NPI: 1851314470
Provider Name (Legal Business Name): KATHLEEN MCDONOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 PORTLAND AVE MC: 952
MINNEAPOLIS MN
55415-1533
US

IV. Provider business mailing address

525 PORTLAND AVE MC: 952
MINNEAPOLIS MN
55415-1533
US

V. Phone/Fax

Practice location:
  • Phone: 612-348-3033
  • Fax: 612-348-7818
Mailing address:
  • Phone: 612-348-3033
  • Fax: 612-348-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0929194
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: