Provider Demographics
NPI:1164956397
Name:ANDERSON, DANIELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FOUNTAIN COURT
Mailing Address - Street 2:SUITE 225
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-323-6021
Mailing Address - Fax:859-323-1670
Practice Address - Street 1:245 FOUNTAIN CT
Practice Address - Street 2:STE 225
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-323-6021
Practice Address - Fax:859-323-1670
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY528802084A0401X, 2083A0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100547440Medicaid