Provider Demographics
NPI:1033699525
Name:DANIELS, DODIE GORDON (NP)
Entity Type:Individual
Prefix:
First Name:DODIE
Middle Name:GORDON
Last Name:DANIELS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:LA
Mailing Address - Zip Code:71463-0629
Mailing Address - Country:US
Mailing Address - Phone:318-634-5475
Mailing Address - Fax:
Practice Address - Street 1:504 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:LA
Practice Address - Zip Code:70638
Practice Address - Country:US
Practice Address - Phone:318-634-5475
Practice Address - Fax:318-634-5476
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily