Provider Demographics
NPI:1417251430
Name:HANSEN, DANIELLE NICOLE (LICENSE)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 S ORCHARD ST
Mailing Address - Street 2:APT. 3
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98466-7708
Mailing Address - Country:US
Mailing Address - Phone:253-324-4281
Mailing Address - Fax:
Practice Address - Street 1:3731 S ORCHARD ST
Practice Address - Street 2:APT. 3
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98466-7708
Practice Address - Country:US
Practice Address - Phone:253-324-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60084763390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60084763OtherCREDENTIAL NUMBER