Provider Demographics
NPI:1407918162
Name:DANLY, DIANE LOUISE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:DANLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 TELECOM DR STE 300W
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:813-871-8183
Mailing Address - Fax:813-871-8184
Practice Address - Street 1:12470 TELECOM DR STE 300W
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-871-8183
Practice Address - Fax:813-871-8184
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME144294207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8117699Medicaid
WAAB32533Medicare ID - Type Unspecified
WA8117699Medicaid