Provider Demographics
NPI:1043617400
Name:DANIELS, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SPRING ST
Mailing Address - Street 2:APT. 10
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 SPRING ST
Practice Address - Street 2:APT. 10
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7967
Practice Address - Country:US
Practice Address - Phone:831-524-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF2576131172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver