Provider Demographics
NPI:1033551429
Name:JANSEN, DANIELLE E (FNP)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:E
Last Name:JANSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:E
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:420 SEMO DR
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1734
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-8929
Practice Address - Street 1:200 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4403
Practice Address - Country:US
Practice Address - Phone:573-472-1770
Practice Address - Fax:573-472-1560
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009034225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033551429Medicaid