Provider Demographics
NPI:1275587917
Name:DORNAN, KIMBERLY E (MACOM, LAC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:E
Last Name:DORNAN
Suffix:
Gender:
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 GRISWOLD ST STE 111208
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-3604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 GRISWOLD ST STE 111208
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-3604
Practice Address - Country:US
Practice Address - Phone:503-449-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00534171100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171100000XOther Service ProvidersAcupuncturist