Provider Demographics
NPI:1386819522
Name:PRODROMIDES, DANIELLE C (LMT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:C
Last Name:PRODROMIDES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 ANASTASIA BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080
Mailing Address - Country:US
Mailing Address - Phone:904-825-0569
Mailing Address - Fax:
Practice Address - Street 1:403 ANASTASIA BLVD.
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-825-0569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47767174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist