Provider Demographics
NPI:1386780732
Name:LOVELL KOLLATH, GWEN ANNE (DC)
Entity type:Individual
Prefix:DR
First Name:GWEN
Middle Name:ANNE
Last Name:LOVELL KOLLATH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3850
Mailing Address - Country:US
Mailing Address - Phone:515-557-0315
Mailing Address - Fax:515-267-5167
Practice Address - Street 1:5460 MERLE HAY RD
Practice Address - Street 2:STE G1
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1239
Practice Address - Country:US
Practice Address - Phone:515-276-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06787111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAV06641Medicare UPIN
IAI16119Medicare ID - Type Unspecified