Provider Demographics
NPI:1407152754
Name:DANIELSON, LAUREN WALLACE (NP-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:WALLACE
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6093
Mailing Address - Country:US
Mailing Address - Phone:850-937-0122
Mailing Address - Fax:
Practice Address - Street 1:8100 N DAVIS HWY
Practice Address - Street 2:MINUTECLINIC
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6093
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874100363LF0000X
FL9353443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02538265Medicaid