Provider Demographics
NPI:1184740664
Name:MCDERMOTT, MADONNA KATHRYN (CNP)
Entity type:Individual
Prefix:
First Name:MADONNA
Middle Name:KATHRYN
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 DUNLAP ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2215
Mailing Address - Country:US
Mailing Address - Phone:651-487-3707
Mailing Address - Fax:
Practice Address - Street 1:2115 SUMMIT AVE
Practice Address - Street 2:MAIL BOX 5056
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1048
Practice Address - Country:US
Practice Address - Phone:651-962-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-122604-5363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health