Provider Demographics
NPI:1114756855
Name:DONNELLAN, KIANNA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KIANNA
Middle Name:MARIE
Last Name:DONNELLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5626
Mailing Address - Country:US
Mailing Address - Phone:218-340-7093
Mailing Address - Fax:
Practice Address - Street 1:1185 TOWN CENTRE DR STE 205
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1370
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant