Healthcare Provider Details

I. General information

NPI: 1437653425
Provider Name (Legal Business Name): DONNA MARIE MCKINNON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 MAIN ST
MIDDLETOWN CT
06457-2732
US

IV. Provider business mailing address

19 GRAND ST
MIDDLETOWN CT
06457-2705
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax: 860-343-7379
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-343-7379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number17804
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17804
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00811900
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP025268
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: