Provider Demographics
NPI:1063989762
Name:DONOVAN, MINDY (RDN, LN)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:RDN, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S ALLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:CHAMBERLAIN
Mailing Address - State:SD
Mailing Address - Zip Code:57325-1757
Mailing Address - Country:US
Mailing Address - Phone:605-234-5048
Mailing Address - Fax:
Practice Address - Street 1:300 S BYRON BLVD
Practice Address - Street 2:
Practice Address - City:CHAMBERLAIN
Practice Address - State:SD
Practice Address - Zip Code:57325-9741
Practice Address - Country:US
Practice Address - Phone:605-234-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0212133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered