Provider Demographics
NPI:1417408865
Name:FREDERICO, DANAE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANAE
Middle Name:
Last Name:FREDERICO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANAE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:26176 LONG ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6557
Mailing Address - Country:US
Mailing Address - Phone:530-228-2451
Mailing Address - Fax:
Practice Address - Street 1:15211 VANOWEN ST STE 200
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3606
Practice Address - Country:US
Practice Address - Phone:818-782-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26279124Q00000X
CA58585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26279OtherDENTAL HYGIENE COMMITTEE OF CALIFORNIA