Provider Demographics
NPI:1346689783
Name:WATSON, DANIELLE MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S WASHINGTON ST
Mailing Address - Street 2:STE 202
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3090
Mailing Address - Country:US
Mailing Address - Phone:208-882-8534
Mailing Address - Fax:
Practice Address - Street 1:619 S WASHINGTON ST
Practice Address - Street 2:STE 202
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3090
Practice Address - Country:US
Practice Address - Phone:208-882-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist