Provider Demographics
NPI:1104007814
Name:LARUE, DANIELLE M
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:LARUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:M
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:NY
Mailing Address - Zip Code:13684-0502
Mailing Address - Country:US
Mailing Address - Phone:315-347-1386
Mailing Address - Fax:
Practice Address - Street 1:114 CASSIDY RD
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:NY
Practice Address - Zip Code:13652-3114
Practice Address - Country:US
Practice Address - Phone:315-347-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265608-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02570414Medicaid