Basic Information
| Provider Information | |||||||||
| NPI: | 1588667166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONNELL | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAWLESS | ||||||||
| OtherFirstName: | DEANNA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2305 SOUTH 65 HIGHWAY, BUILDING A | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605566677 | ||||||||
| FaxNumber: | 6608313346 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 SOUTH 65 HIGHWAY, BUILDING A | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653403702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608867800 | ||||||||
| FaxNumber: | 6608313346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 150934 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1588667166 | 05 | MO | MEDICAID |