Provider Demographics
NPI:1083398010
Name:HUDSON, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:HUDSON
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 1:812 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1117
Mailing Address - Country:US
Mailing Address - Phone:920-648-5187
Mailing Address - Fax:
Practice Address - Street 1:812 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1117
Practice Address - Country:US
Practice Address - Phone:920-648-5187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19962-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist