Provider Demographics
NPI:1134698772
Name:CONCILLA, DANIELLE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LYNN
Last Name:CONCILLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-3121
Practice Address - Country:US
Practice Address - Phone:904-542-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant