Provider Demographics
NPI:1104354448
Name:DONOVAN, MARY KATHRYN (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 DELAWARE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-2017
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:625 DELAWARE AVE STE 204
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1007
Practice Address - Country:US
Practice Address - Phone:716-882-3151
Practice Address - Fax:716-886-4002
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY731782163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY731782OtherLICENSE