Provider Demographics
NPI:1417461807
Name:TALAVERA, DANIELLE CHRISTINE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:CHRISTINE
Last Name:TALAVERA
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 1:43105 PROVIDENCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-5282
Mailing Address - Country:US
Mailing Address - Phone:734-730-6922
Mailing Address - Fax:
Practice Address - Street 1:2561 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3313
Practice Address - Country:US
Practice Address - Phone:248-682-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291021363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics